Science Based Medicine

APRIL 21, 2024

New documents released yesterday confirm his prediction." - Dr. Jay Bhattacharya January 2024 The post Science Based Satire: BOMBSHELL NEWS!!! "Last year, @WashburneAlex made a bombshell prediction supporting the lab leak theory. The Virus I Told You Not to Worry About and Worked to Infect You With… CAME FROM A LAB!!!

Documentation/Coding 111

Documentation/Coding 111

The Trauma Pro

AUGUST 15, 2023

MTP logistics include details such as who will be delivering the blood, what actually goes in each cooler, what ratios should be used, limitations imposed by the use of frozen plasma, and documentation. Documentation is critically important, both in the trauma bay and the blood bank. And there are plenty around all the time!

Documentation/Coding 130

Documentation/Coding Best Practices Resuscitation Administration 130

The Trauma Pro

NOVEMBER 10, 2023

You can download the full document using the link at the bottom of this post. Document your consultation results in writing (paper or EMR) promptly. Click here to download a sample Trauma Services consultant guidelines document. We have disseminated guidelines to our colleagues, and I wanted to touch on some of the main points.

Documentation/Coding 147

Documentation/Coding Best Practices 147

Resus Review

FEBRUARY 12, 2015

Part of performing a bedside percutaneous tracheostomy is the procedural documentation. Given that this is a surgical procedure, the documentation should be more thorough than you may be accustomed to doing for an arterial line or central line. I have included a sample procedure note below.

Documentation/Coding 40

Documentation/Coding 40

EMCrit

DECEMBER 10, 2023

Some authors on the ATS document were from Europe, and similarly some authors […] EMCrit Project by Josh Farkas. Within the past year, two major societies have released guidelines on ARDS: the ATS (American Thoracic Society) and the ESICM (European Society of Intensive Care Medicine).

Documentation/Coding 132

Documentation/Coding 132

EMDocs

MAY 9, 2024

Exam documents that he is alert and oriented but “tired appearing” and “not appearing post-ictal.” Defense : The EP did address the seizure when he documented “not post-ictal.” There is no negligence, as the documentation supports reasonable judgment. The triage nurse records the event as a “seizure” lasting 7 minutes.

Seizures 80

Seizures Dehydration Documentation/Coding Infectious Diseases 80

Science Based Medicine

OCTOBER 16, 2023

This is an old finding that needs to be documented periodically and shows why the acceptance of non-science-based treatments by physicians endangers vaccination efforts. A recent study reaffirms the high degree of correlation among physicians between antivax views and an embrace of quackery.

Documentation/Coding 124

Documentation/Coding 124

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 and malaise. He has no urinary or bowel symptoms. His past medical history is unremarkable. He looks well by ED standards. After a focused history and physical examination, you narrow the differential to diverticulitis.

Documentation/Coding 113

Documentation/Coding Wellness Infectious Diseases EMS 113

Emergency Live

JANUARY 20, 2024

One of the earliest documented female firefighters was Molly Williams, a member of Oceanus Fire Company No. The Pioneers in the Fight Against Fires in the Victorian Era The Early Flames of Change The history of women in firefighting has deep roots dating back to the early 1800s.

Documentation/Coding 85

Documentation/Coding 85

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 81

Pediatrics Documentation/Coding EMS Wellness 81

Emergency Live

JANUARY 24, 2024

These confraternities, originating in Italy, have deep roots dating back to the Middle Ages, with the earliest historical documentation attesting to the foundation of the Misericordia of Florence […] The post The Misericordie: a history of service and solidarity appeared first on Emergency Live.

Documentation/Coding 74

Documentation/Coding 74

Science Based Medicine

AUGUST 17, 2023

A new paper documents COVID-19 medical misinformation shared by US physicians on social media The post Examining COVID-19 misinformation propagated by US physicians first appeared on Science-Based Medicine.

Documentation/Coding 83

Documentation/Coding 83

Mind The Bleep

NOVEMBER 21, 2023

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. Drugs/Allergies When documenting drugs – try to get the dose and frequency (this can be found on Summary Care Records from the GP if you have access).

Documentation/Coding 52

Documentation/Coding COPD Wellness EKG/ECG 52

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 95

Documentation/Coding EMS Operations Emergency Department 95

Total Medical ComplianceHIPAA

DECEMBER 7, 2023

Secure Physical Documents: With increased holiday traffic in workplaces, it’s important to secure physical documents containing patient information. Implement measures such as locking file cabinets and guaranteeing documents are not left unattended in public spaces.

Documentation/Coding 52

Documentation/Coding 52

Taming the SRU

JULY 14, 2023

Hughes Pitfalls: We are not multitasking, we are task switching Instead of shotgun orders, do minimum workup for patients with a specific complaint Goal is disposition in the emergency department, so “hit the box” does not just include seeing patients but also their documentation and disposition On shift hacks: Documentation - start note with sign (..)

Documentation/Coding 58

Documentation/Coding Emergency Department 58

American Medical Compliance

APRIL 23, 2024

There have been numerous changes to the documents over time. GCP Training Requirements The GCP policy expects investigators and clinical trial staff to retain documentation of their training, and as needed, provide it to the National Institute of Health upon request.

Documentation/Coding 52

Documentation/Coding Research Best Practices Outcomes 52

EMDocs

JUNE 28, 2023

EMS report includes concern for CVA, with variable documentation of face and extremity weakness. Nursing documentation includes the presence of a facial droop. There, his initial neuro exam is documented as normal, but a head CT reveals evidence of a possible acute CVA in the right hemisphere.

Documentation/Coding 66

Documentation/Coding EMS Stroke Patient Safety 66

Emergency Medicine Journal

NOVEMBER 28, 2023

Measures of time taken (mins : secs), number information technology (IT) support calls, quality of documentation (using a visual analogue scale), and cognitive load (NASA Task Load Index) were recorded and analysed. Quality of documentation improved with OSLER 4.3 ± 0.3 vs 2.7 ± 0.9 (p p < 0.001). 95% CI 2.3 – 3.5

Documentation/Coding 40

Documentation/Coding Emergency Department 40

American Medical Compliance

APRIL 16, 2024

Furthermore, advance directives are legal documents that provide instructions for medical care and only go into effect if you cannot communicate your wishes. In addition, advance care planning involves discussing and preparing for future decisions about your medical care if you become seriously ill or unable to communicate your wishes.

Documentation/Coding 100

Documentation/Coding Research Outcomes 100

Sensible Medicine

DECEMBER 18, 2023

Now let’s compare the two documents. From their document. The USPSTF has issued draft guidance that emphasizes diet and exercise. The AAP champions surgery and medications. I have been critical of the AAP’s endorsement — a topic I discussed here. Let’s take a look at the USPSTF. This is Orwellian.

Pediatrics 141

Pediatrics Documentation/Coding Burns Academics 141

Emergency Medicine Journal

MARCH 21, 2024

’ –Audre Lorde It has been over 4 years since 14 November 2019 when the first documented case of COVID-19 emerged. ‘It is not our differences that divide us. It is our inability to recognize, accept, and celebrate those differences.’

Documentation/Coding 52

Documentation/Coding Outcomes 52

Total Medical ComplianceHIPAA

MARCH 12, 2024

The Compliance Officer must exhibit problem-solving skills to assess and address potential risks, organizational skills to manage documentation and a sense of responsibility and accountability for ensuring the organization’s compliance. Having a collaborative attitude in working with other team members is essential.

Documentation/Coding 52

Documentation/Coding 52

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

Stop and Think

JANUARY 1, 2024

They sit in a Google document. It will be a working document. We’ve already written many of these reviews. It would take another year to finish. Our change of heart happened recently. We’ve decided to write this book on Substack. One review at a time. They will come out as separate posts.

Documentation/Coding 75

Documentation/Coding Wellness EKG/ECG Hospitals 75

Total Medical ComplianceHIPAA

NOVEMBER 13, 2023

Develop a documented process for managing exceptions to information requests, aligning them with consent, privacy, and regulatory requirements. Create clear documentation for exceptions on a case-by-case basis for records management purposes. This process should encompass the eight exceptions mentioned here: [link].

Documentation/Coding 52

Documentation/Coding Hospitals 52

American Medical Compliance

MARCH 18, 2024

Requirements Specific to Vermont In the state of Vermont on or before January 1, 2027, each healthcare facility must implement and maintain a documented workplace violence prevention and crisis response policy that meets or exceeds the standards of this section for the benefit of staff providing healthcare.

Psychiatric 95

Psychiatric Documentation/Coding Hospitals 95

AENJ: Current Issue

SEPTEMBER 30, 2023

A team at a Level 1 trauma center recognized the need for ED-friendly documentation and a validated ED skin risk assessment instrument. Emergency care professionals must be proactive about PI early identification and prevention strategies. The Bjorklund 25-item ED Skin/Risk Assessment Tool was selected.

Emergency Department 97

Emergency Department Patient Safety Documentation/Coding Research 97

The Trauma Pro

JUNE 20, 2023

Documentation provided by the nurse or other providers in the medical record must demonstrate that they were in some way involved in care of the patient. Following are the basics of malpractice as it relates to nurses. A scope of duty must be established within the relationship.

Documentation/Coding 130

Documentation/Coding Operations Hospitals 130

RebelEM

MAY 15, 2023

Frantically look through the assisted care documents for do-not-resuscitate paperwork Place a chest tube on the left side Place a chest tube on the right side Start noninvasive or mechanical ventilation FOR THE RIGHT ANSWER CLICK ON THE ROSH REVIEW LOGO BELOW References: Dixon A. The patient’s emergent portable chest X-ray is shown below.

EMS 82

EMS Documentation/Coding Resuscitation 82

Total Medical ComplianceHIPAA

MAY 25, 2022

But there’s a twist, the malware inside the PDF is still Word document. The Word document is named “has been verified”. The pop-up message that asks the user to open the Word document says, “The file ‘has been verified’.” The user receives an email named “Remittance Invoice” with the infected PDF attached. docx) file.

Documentation/Coding 52

Documentation/Coding 52

PulmCCM

JANUARY 29, 2024

Read the document for all the details (it’s not long). In accordance with the fraught ethical and emotional factors surrounding organ donation, this section is the tersest, least explicated section of the document. PulmCCM is not affiliated with the American Heart Association. Here’s PulmCCM’s take on the new changes.

Seizures 115

Seizures CPR Documentation/Coding Hyperthermia / Hypothermia 115

American Medical Compliance

SEPTEMBER 10, 2023

According to the Joint Commission, all aspects of informed consent must be documented “in a form, progress notes, or elsewhere in the record.” What Documents are Required to Obtain a Patient’s Consent? Languages: American English Key features: Audio narration, learning activity, and post-assessment.

Blood Transfusions 52

Blood Transfusions Documentation/Coding Operations 52

American Medical Compliance

FEBRUARY 17, 2024

Maintain Comprehensive Recordkeeping Document workplace injuries and illnesses. By accurately documenting workplace injuries, organizations can track injury trends over time, identify common causes of injuries, and implement targeted interventions to prevent future incidents.

Best Practices 105

Best Practices PPE Infectious Diseases Documentation/Coding 105

Emergency Medicine Journal

MAY 23, 2023

We investigated the association between bystander CPR and the likelihood of ventricular fibrillation (VF) or ventricular tachycardia (VT) as the first documented cardiac rhythm. The first documented cardiac rhythm was compared between patients who received bystander CPR and those who did not, using a 1:2 propensity score-matched analysis.

Resuscitation 40

Resuscitation CPR Hospitals Documentation/Coding 40

Emergency Medicine Journal

NOVEMBER 28, 2023

Age, Gender, Clinical Frailty Score (CFS) and documentation of ‘WMTY’ was analysed. 468 (79%) patients had documentation of WMTY. Data was routinely collected from Comprehensive Geriatric Assessments, and entered prospectively onto Excel by a trained administrator. Results 592 patient responses were analysed.

Emergency Department 40

Emergency Department Documentation/Coding Administration Hospitals 40

ACEP Now

OCTOBER 3, 2023

This document is an update of guidelines first published in 2000, and then updated in 2007. Confounders to the GCS such as seizure and post-ictal phase, ingestions and drug overdose, as well as medications administered in the prehospital setting that impact GCS score should be documented. 2019;154(7):e191152.

Documentation/Coding 98

Documentation/Coding Fluid Resuscitation Resuscitation Pediatrics 98