Mind The Bleep

FEBRUARY 2, 2025

” Yes, I have seen clerking look like this and I can confirm, it does not go down well. Unless you’re documenting something hilarious, please keep it brief and to the point. History of Presenting Complaint In this section use SOCRATES to document the pain.

Documentation/Coding 95

Documentation/Coding COPD EKG/ECG Wellness 95

Emergency Medicine Cases

MARCH 26, 2020

Not only do we discuss the details of all PPE from head protection to footwear, but we give tips on the equally important non-PPE protection as well. We touch on PPE conservation strategies as we struggle with supplies, give you the bottom line on donning/doffing sequencing, and discuss the core principles of the protected code blue.

PPE 52

PPE Documentation/Coding Resuscitation Wellness 52

RebelEM

JUNE 29, 2023

REBEL Cast Ep119: A Discussion with Scott Weingart on the CT FIRST Trial Click here for Direct Download of the Podcast Timing Is 6hrs reasonable because most pts excluded because of this Right before heading up to ICU seems good 1st couple hours after ROSC…pts are high risk for re-coding Where Not single coverage or stand-alone EDs Optimize and transfer…scans (..)

CPR 142

CPR EMS Documentation/Coding Outcomes 142

EM Ottawa

SEPTEMBER 28, 2023

You are treating a 43-year-old male with two days of left lower quadrant abdominal pain, a documented fever of 38.4 He looks well by ED standards. and malaise. He has no urinary or bowel symptoms. His past medical history is unremarkable. After a focused history and physical examination, you narrow the differential to diverticulitis.

Documentation/Coding 115

Documentation/Coding Wellness Infectious Diseases EMS 115

American Medical Compliance

MARCH 11, 2024

These are recordkeeping and documentation. While the primary focus in dentistry is patient health and well-being, carefully keeping records is equally needed. Informed Consent Documentation Before initiating any treatment, informed consent must be obtained from the patient or their legal guardian.

Documentation/Coding 105

Documentation/Coding Best Practices Operations Outcomes 105

Science Based Medicine

AUGUST 14, 2024

These benefits are all well researched and copiously documented. We have often stated here on SBM that vaccine programs are the most effective, and most cost effective, public health measures in human history. They save lives, prevent disease, and save money.

CDC 97

CDC Documentation/Coding Research Wellness 97

Sensible Medicine

DECEMBER 18, 2023

Now let’s compare the two documents. That is my conclusion as well, and I favor large, pragmatic randomized trials in adults and kids with staggered starting times (adults first — to protect kids from harms we may not yet know). From their document. The AAP champions surgery and medications. Better food?

Pediatrics 145

Pediatrics Documentation/Coding Burns Academics 145

Dr. Smith's ECG Blog

MARCH 14, 2024

It is well known that NOMI usually has a normal ECG or nonspecific ECG. We also studied 7 years of Code STEMI patients requiring emergent reperfusion, and found that 4% presented with an ECG labeled ‘normal’, often confirmed by the final blinded interpretation.

EKG/ECG 122

EKG/ECG Documentation/Coding Patient Safety Outcomes 122

Dr. Smith's ECG Blog

OCTOBER 18, 2023

4,5] We have now formally studied this question: Emergency department Code STEMI patients with initial electrocardiogram labeled ‘normal’ by computer interpretation: a 7-year retrospective review.[6] have published a number of warnings about the previous reassuring studies.[4,5] Am J Emerg Med. 2022 ; 55 : 180 - 182 6.

EKG/ECG 122

EKG/ECG Documentation/Coding Emergency Department Outcomes 122

Stop and Think

JANUARY 1, 2024

Well, that can be a problem. Sometimes things we do are well grounded in evidence. Things like reading ECGs, echocardiograms, as well as learning to do procedures. Well, do you know the actual trials underpinning this evidence? They sit in a Google document. It will be a working document.

Documentation/Coding 98

Documentation/Coding Wellness EKG/ECG Hospitals 98

American Medical Compliance

APRIL 1, 2024

What you will learn Principles, code of professional conduct, and advisory opinions Patient Autonomy Nonmalfience Benefience Indiana Statuses and Administrative Rules Licensure of Dentists Licensure of Dental Hygienists Details Course length: 2 hours. These are the ADA Principles of Ethics and Code of Professional Conduct (ADA Code).

Documentation/Coding 59

Documentation/Coding Administration Wellness 59

EM Ottawa

DECEMBER 28, 2023

There is a well-documented correlation amongst EMS and adult ED physicians who provide less pediatric care to […] The post Pediatric Traumatic Cardiac Arrest appeared first on EMOttawa Blog. Trauma is the leading cause of child and youth mortality globally (1). Pediatric trauma is a high acuity but low frequency event (2).

Pediatrics 83

Pediatrics Documentation/Coding EMS Wellness 83

American Medical Compliance

OCTOBER 3, 2024

As dental professionals, it’s crucial to understand and adhere to OSHA dental compliance standards to ensure the well-being of both staff and patients. This can be achieved by maintaining a centralized document repository. Have a digital document management system or a physical binder in a prominent area of the dental office.

PPE 105

PPE Hazardous Materials Documentation/Coding Operations 105

EMDocs

AUGUST 22, 2024

13 Interventions may include: Ascertaining a patient’s preferred language early in the clinical encounter (during registration, for instance), and clearly documenting this preference in a place that is visible to all providers. Well-meaning providers who are not highly fluent may contribute to miscommunication and diagnostic errors.

Documentation/Coding 91

Documentation/Coding Emergency Department Federal Emergency Management Agency Best Practices 91

EMDocs

JULY 25, 2024

The nurse completes the Columbia-Suicide Severity Rating Scale (C-SSRS) and documents that the patient’s recent thoughts of killing himself and his detailed plan makes him “High Risk” for suicide. There is no documented handoff to the on-coming emergency physician (EP) who assumes care. ” 0700 : The PA-C goes off-shift.

Documentation/Coding 91

Documentation/Coding Hospitals Patient Safety Emergency Department 91

Stop and Think

NOVEMBER 19, 2023

Also well known—from old data—was that myocarditis is a cause of cardiac arrest during sport. This was a 20-year survey in which the authors used 4 independent databases to document the incidence and causes of sudden cardiac death in NCAA athletes. Young males had the highest risk of this adverse effect. But it was real.

Documentation/Coding 130

Documentation/Coding Wellness Resuscitation 130

Pediatric EM Morsels

FEBRUARY 2, 2024

In one ED study, ALL cases of missed travel-related illness did not have a documented travel history in their ED note , whereas 90% of the identified travel-related illnesses had a provider documented travel history (Greenky 2022) Those who are visiting friends and relatives (VFR) are typically at highest risk.

Infectious Diseases 161

Infectious Diseases Pediatrics Sepsis Documentation/Coding 161

American Medical Compliance

AUGUST 14, 2024

This training not only raises awareness but also empowers dental teams to take action, ensuring that they can contribute to the safety and well-being of their patients. ” This broad definition underscores the variety of ways in which a child’s well-being can be compromised.

Burns 105

Burns Documentation/Coding Wellness 105

Sensible Medicine

MAY 16, 2024

This works reasonably well. They documented that these patients had high vagal tone. A few short words about our conversation: Two decades have passed and electrophysiologists have learned little about how to ablate atrial fibrillation. Now, and then, we simply ablate circles around the orifices of the pulmonary veins.

Documentation/Coding 99

Documentation/Coding Wellness 99

Dr. Smith's ECG Blog

OCTOBER 23, 2023

Macroscopic T-Wave Alternans: A Red Flag for Code Blue. This 1910 description by Lewis serves well to this day to remind us of the 2 principal clinical situations in which electrical alternans is most often encountered: i ) Supraventricular reentry tachycardias; and , ii ) Pericaradial tamponade. J Am Coll Cardiol. doi: 10.1016/j.jacc.2005.08.066.

EKG/ECG 134

EKG/ECG Documentation/Coding Psychiatric EMS 134

Dr. Smith's ECG Blog

JANUARY 5, 2024

The documentation does not describe any additional details of the history. They also documented "Reproducible chest tenderness." The proximal LAD has mild disease, but the distal LAD and diagonal branches are not well evaluated in this view. The distal LCx is seen, and the OM is not well visualized here.

EKG/ECG 123

EKG/ECG Burns Urgent Care Documentation/Coding 123

EMDocs

OCTOBER 3, 2023

This is also where keeping up with documentation starts to slip. You’ll need to put the following tasks in a rank order list: new patient evaluations, dispositions, managing critical or potentially critical patients, results review, team huddle, running the board, calling consults, doing procedures, and documentation. It’s up to you.

Documentation/Coding 106

Documentation/Coding EMS Operations Emergency Department 106

RebelEM

DECEMBER 23, 2024

There has been ongoing study about the clinical significance of these effects, as well as whether and for whom LR might provide meaningfully better clinical outcomes ( Myburgh 2013 , Self 2018 , Semler 2018 , Self 2020 ).

Fluid Resuscitation 121

Fluid Resuscitation Resuscitation Documentation/Coding Outcomes 121

Dr. Smith's ECG Blog

SEPTEMBER 12, 2024

The paramedic called the EM physician ahead of arrival and discussed the case and ECGs, and both agreed upon activating "Code STEMI" (even though of course it is not STEMI by definition), so that the acute LAD occlusion could be treated as fast as possible. So the cath lab was activated.

EKG/ECG 124

EKG/ECG EMS Documentation/Coding Shock 124

Total Medical ComplianceHIPAA

AUGUST 15, 2024

Document what worked well and what did not. Clear Communication Channels : Confirm that communication channels are well-defined and tested. Documentation and Compliance Comprehensive Documentation : Maintain detailed documentation of the DRP, including all tests, training sessions, and updates.

Documentation/Coding 59

Documentation/Coding Best Practices Risk Management Wellness 59

Mind The Bleep

FEBRUARY 2, 2025

This is a tricky area to cover as it can be challenging to us both personally and professionally when things dont go well with a colleague, particularly when we know that this might impact patient care and/or our own mental health. A simple sentence like This interaction hasnt gone well. It is hard to speak up sometimes.

Documentation/Coding 98

Documentation/Coding Outcomes Burns Wellness 98

Sensible Medicine

AUGUST 2, 2024

I often say to patients (as I apologize for documenting while I get to know them) that I had sworn as a medical student never to be the doctor that types during visits—and when I first became an attending, I held to that. Ideally, I would have a schedule where I could document in the time after a patient leaves the visit.

Documentation/Coding 75

Documentation/Coding Administration Wellness 75

American Medical Compliance

AUGUST 29, 2024

Just like medical errors, falls are preventable incidents that require careful monitoring, proper safety protocols, and prompt interventions to minimize risk and protect patient well-being. Understanding this definition helps healthcare providers recognize the importance of fall prevention as a critical aspect of patient safety.

Patient Safety 98

Patient Safety Documentation/Coding Wellness 98

Don't Forget the Bubbles

AUGUST 23, 2023

Definitive emotional support is critical to our emotional and psychological well-being. 2016) “Implementation of a Post-Code Pause: Extending Post-Event Debriefing to Include Silence”. 2012) “Implementation of a Rapid Post-Code Debrief Quality Improvement Project in a Community Emergency Department Setting”. & Liska, H.

Emergency Department 98

Emergency Department Resuscitation Documentation/Coding Best Practices 98

American Medical Compliance

AUGUST 7, 2024

It protects the health and well-being of staff. For example, CMS requires accurate and timely documentation of patient care to ensure proper billing and reimbursement. This plan should clearly define your policies and procedures regarding patient privacy, billing, documentation, and safety.

Hazardous Materials 105

Hazardous Materials Documentation/Coding Legal Issues Patient Safety 105

American Medical Compliance

FEBRUARY 17, 2024

Ensuring the safety and well-being of both patients and staff is paramount. Maintain Comprehensive Recordkeeping Document workplace injuries and illnesses.

Best Practices 105

Best Practices PPE Infectious Diseases Documentation/Coding 105

ACEP Now

DECEMBER 6, 2024

This case report documents the first known instance of using NTG during an emergency department resuscitation to treat a patient in cardiac arrest due to severe coronary artery vasospasm. Cardiac arrest secondary to myocardial ischemia from coronary vasospasm is well documented.

Resuscitation 98

Resuscitation EKG/ECG Documentation/Coding COPD 98

Sensible Medicine

JUNE 11, 2024

This interface shortens the time required for human-to-computer interaction by transforming an input given through natural language into almost any form, from text to images to computer code. This responsibility extends to patients as well, ensuring that their voices and needs are central to the innovation process.

Documentation/Coding 87

Documentation/Coding Wellness Outcomes Research 87

Mind The Bleep

FEBRUARY 2, 2025

However, as an F1, you may well know the patient best and therefore you may be best placed to refer the patient. She is otherwise in good health and is responding well to chemotherapy. Often one of the scariest things you can do as you will most likely be speaking to a more senior colleague in an unfamiliar speciality.

Radiology 96

Radiology Radiology Sepsis Documentation/Coding 96

The Trauma Pro

DECEMBER 26, 2023

Screening looks at patient factors such as age, obesity, and previous VTE, as well as injury risk factors like spine and pelvic fractures and decreased mobility. But the key fact is that every compression device manufacturer includes existing DVT as a contraindication in their product documentation.

Fractures 124

Fractures Documentation/Coding Hospitals Research 124

RebelEM

JUNE 22, 2023

Population: Adults aged 30-85 years of age with BMI > 25 ( > 23 in those identifying as Asian or Latino) who had COVID-19 symptoms for fewer than 7 days and a documented SARS-CoV-2 positive PCR or antigen test within 3 days of enrollment without prior SARS-CoV-2 infection. Broad inclusion criteria increasing external validity.

Outcomes 135

Outcomes Research Documentation/Coding Wellness 135

EMDocs

JUNE 8, 2023

and 9 hours of symptom onset; stroke symptoms that started during sleep were assumed to have started halfway between the actual last known well and the time of wake-up. Subsequently reduced enrollment to 310 patients because no patients had been lost to follow-up or had insufficient data documented.

Stroke 87

Stroke Administration Documentation/Coding Outcomes 87