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

Clinical Correlations

NOVEMBER 1, 2024

By Chloe Fong Peer Reviewed The correlation between vitamin deficiency and alcohol use disorder (AUD) has been well documented in the literature, with a study from 1963 finding that 70% of patients admitted to the hospital.

Documentation/Coding 52

Documentation/Coding Hospitals Wellness 52

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

Pediatric EM Morsels

OCTOBER 27, 2023

Taking care of a critically ill child can be nerve-racking to say the least, and downright petrifying for those who don’t do it frequently, even if they are well-trained and brilliant clinicians. Sinha 2012] It is useful in the prehospital setting , correlating well with actual weight and ED Broselow weight. Broselow does not.

Pediatrics 269

Pediatrics Resuscitation Documentation/Coding Wellness 269

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 73

CDC Documentation/Coding Research Wellness 73

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 110

Documentation/Coding Wellness Infectious Diseases EMS 110

Ken Grauer, MD

FEBRUARY 28, 2023

Figure-2: I've color-coded P waves from Figure-1 according to P wave morphology ( See text ). NOTE: For clarity — I've color-coded P waves in the long lead II rhythm strip according to morphology. Remember — 12 leads are better than one! Microvascular dysfunction — cardiac vasculitis — intravascular thrombosis.

EKG/ECG 195

EKG/ECG Documentation/Coding Sepsis COPD 195

Ken Grauer, MD

JUNE 22, 2024

See ECG Blog #313 — as well as My Comment at the bottom of the page in the June 17, 2024 post in Dr. Smith's ECG Blog ). I cannot tell you how many times such "written" documentation was off, due to the tendency to inscribe a normal number instead of counting for 30 seconds because "the patient looked like they were breathing normally".

EKG/ECG 433

EKG/ECG Stroke Documentation/Coding Wellness 433

American Medical Compliance

OCTOBER 25, 2024

Compliance isn’t just a box to check—it’s a vital responsibility that safeguards patient well-being and protects organizations from significant financial losses. Shockingly, over $54 billion is stolen each year through scams targeting patients and insurance companies with fraudulent medical charges, according to the NHCAA.

Documentation/Coding 81

Documentation/Coding Operations Best Practices Shock 81

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 78

Pediatrics Documentation/Coding EMS Wellness 78

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 90

Documentation/Coding Best Practices Operations Outcomes 90

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

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 145

CPR EMS Documentation/Coding Outcomes 145

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 82

Documentation/Coding Emergency Department Best Practices Federal Emergency Management Agency 82

Stop and Think

NOVEMBER 19, 2024

CMS has already issued a special billing code for extra payment of the device. High-volume procedural docs will gain status in their employed healthcare system as well as in the profession. Here is a Tweet from Christopher Ellis at Vanderbilt describing an implant at the same time as ablation.

Stroke 126

Stroke Documentation/Coding Outcomes Wellness 126

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 97

PPE Hazardous Materials Documentation/Coding Operations 97

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 82

Documentation/Coding Hospitals Patient Safety Emergency Department 82

Dr. Smith's ECG Blog

MARCH 4, 2024

I have often written about how an ECG interpreted as "normal" by a conventional algorithm may well be manifesting OMI, or even long QT or hyperkalemia. link] Or use the QR code: 10 Cases: Case 1 Do you want to be interrupted to view what the computer calls normal or nonspecific ECGs? 2 cases at once! You can use it an unlimited amount.

EKG/ECG 113

EKG/ECG Documentation/Coding Wellness Resuscitation 113

AENJ: Current Issue

JULY 31, 2024

Originally deemed a “stroke code” in the field, the patient was immediately transferred to the computerized tomography scanner. The key features of caring for a patient experiencing carotid dissection, as well as their expected prognosis and care course, are also expounded upon.

Stroke 42

Stroke Documentation/Coding Emergency Department Wellness 42

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 62

Documentation/Coding Administration Wellness 62

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 142

Pediatrics Documentation/Coding Burns Academics 142

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 118

EKG/ECG Documentation/Coding Emergency Department Outcomes 118

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 110

EKG/ECG Documentation/Coding Patient Safety Outcomes 110

SheMD

MAY 11, 2023

Transcripts were coded to sort data into “leadership occurrences” or “unrelated to leadership” as well as critical treatment decisions. CPR-related performance items were coded by the second as present or absent. How they measured things: Data was studied through video recordings collected for analysis.

Leadership 52

Leadership Documentation/Coding Teamwork CPR 52

ACEP Now

OCTOBER 29, 2024

Our nurse did not study Paul Ekman’s Facial Action Coding System for Action Units to code “fear” in the patient’s face. 4 However, emergency physicians rely on gestalt to predict outcomes well. Thiruganasambandamoorthy V, Kwong K, Wells GA, et al. What do you think the prognosis is for that patient we achieved ROSC?

Emergency Department 59

Emergency Department Mass Casualty Incidents Documentation/Coding Sepsis 59

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 91

Burns Documentation/Coding Wellness 91

Mind The Bleep

NOVEMBER 21, 2023

” 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 52

Documentation/Coding COPD EKG/ECG Wellness 52

American Medical Compliance

FEBRUARY 2, 2024

Use of the ATD Standard Cal/OSHA requires employers covered by the Aerosol Transmissible Disease (ATD) Standard (California Code of Regulations, Title 8, Section 5199) to protect employees from airborne infectious disease such as COVID-19 and pathogens transmitted by aerosols. Employees who are working from home. 8, § 5199) (section 5199).

Infectious Diseases 52

Infectious Diseases Documentation/Coding PPE Wellness 52

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 89

Documentation/Coding Wellness 89

Ken Grauer, MD

NOVEMBER 30, 2024

Although small in amplitude — these P waves are fairly well seen in lead II. As always — I favor systematic assessment of the cardiac rhythm by the P s , Q s , 3 R Approach ( See ECG Blog #185 for review ). Returning to Figure-1 — I look for the P s, Q s and 3 R s: P waves are clearly present in today's rhythm.

EKG/ECG 318

EKG/ECG Documentation/Coding Wellness 318

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 118

EKG/ECG EMS Documentation/Coding Shock 118

RebelEM

AUGUST 22, 2024

1,2 Intra-arterial (IA) tPA has also shown benefit but is less well studied. Patients whose last known well (LKW) time was within 24 hours of presentation. Documented at the following time points: Before treatment. Administration of intravenous tissue plasminogen activator (IV tPA) within 4.5 Within 24 hours after treatment.

Stroke 85

Stroke Administration Outcomes Documentation/Coding 85

Emergency Medicine Journal

NOVEMBER 28, 2023

SOCIAL PROBLEM (MEDICALLY WELL) 58 1 27 46.6 NEEDLESTICK/BODY FLUIDS) 113 0 12 10.6 CRYING INFANT 108 0 16 14.8 THROAT : FOREIGN BODY IN THROAT/MOUTH 108 0 18 16.7 JOINT SWELLING 103 0 28 27.2 NOSE : FOREIGN BODY 100 0 4 4 0[0 , 3.7] NOSE : INJURY 100 0 2 2 0[0 , 3.7] PROBLEM RELATED TO PENIS 99 1 8 8.1 COLD PAINFUL LIMB 88 4 57 64.8

Documentation/Coding 40

Documentation/Coding Sexual Assault Hyperthermia / Hypothermia Head Injuries 40

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 98

Documentation/Coding EMS Operations Emergency Department 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 72

Documentation/Coding Wellness Outcomes Research 72

ACEP Now

JUNE 7, 2023

Whereas previous versions of GPT were unable to pass the medical examinations, GPT-4 demonstrated scores of approximately 85 percent correct on each Step of USMLE, well above the passing threshold. Future versions are likely to have greater accuracy and error-checking abilities, as well as improved domain-specific generative abilities.

Documentation/Coding 78

Documentation/Coding Wellness Administration Research 78

EMDocs

DECEMBER 4, 2023

The Wells’ Criteria for DVT can help risk stratify [2,3]. If the patient’s Wells score is ≤ 0, DVT is nearly clinically excluded and no further immediate lab or ultrasound is necessary. In patients with a Wells’ score of 1-2 (moderate risk), DVT can be ruled out with a negative d-dimer rather than an US. mg/kg for 24 hours.

Ultrasounds 71

Ultrasounds Documentation/Coding Wellness EMS 71