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 73

Documentation/Coding Hospitals Patient Safety Emergency Department 73

The Trauma Pro

JUNE 21, 2024

This situation was first documented in a paper published in the 1960s, which noted that VIP patients have worse outcomes. The VIP syndrome occurs in healthcare when a celebrity or other well-connected “important” person receives a level of care that the average person does not. Who is a VIP? It may be a celebrity. A family member.

Documentation/Coding 290

Documentation/Coding Outcomes Hospitals Wellness 290

American Medical Compliance

MARCH 11, 2024

These are recordkeeping and documentation. In a survey , dental providers agree that careful and precise recordkeeping is indispensable, emphasizing the importance of documenting elements such as patient histories, examination results, diagnoses, radiographs, treatment plans, consent forms, and clinic notes.

Documentation/Coding 105

Documentation/Coding Best Practices Operations Outcomes 105

Emergency Medicine News

MARCH 31, 2024

An abstract is unavailable.

Documentation/Coding 40

Documentation/Coding 40

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

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

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 105

Documentation/Coding 105

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

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 134

Documentation/Coding 134

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 118

Documentation/Coding 118

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 117

Documentation/Coding Wellness Infectious Diseases EMS 117

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 98

Documentation/Coding 98

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 98

Documentation/Coding 98

The Trauma Pro

JULY 16, 2024

Typical options would be direct correspondence with a liaison for simple one-service issues or discussion (and good documentation) from a morbidity and mortality conference. Alternate review pathways There are more options for review other than the primary and secondary pathways mentioned in the previous paragraph.

Operations 147

Operations Documentation/Coding Pediatrics 147

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 82

Seizures Dehydration Documentation/Coding Infectious Diseases 82

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 85

Pediatrics Documentation/Coding EMS Wellness 85

EMDocs

JUNE 13, 2024

We just don’t document it. If we don’t use printed instructions, document our verbal instructions regarding the most common side effects of the drug(s) being prescribed. Documenting our warnings should be standard care. Giving written instructions about a drug is the pharmacist’s job.

Documentation/Coding 77

Documentation/Coding Patient Safety Emergency Department Hospitals 77

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 84

Documentation/Coding 84

Dr. Smith's ECG Blog

JUNE 13, 2024

Her first set of vitals were documented: BP 116/57 Pulse 94bpm Respiratory rate 24/min O2 sat 90% on room air Temp 97F She had been cleaning a Jeep in the sun, and was sunburned. The physician documented “normal sinus rhythm”. The physician documented that she was “improved” and the patient was discharged. CK MB was 1.9

EKG/ECG 92

EKG/ECG Documentation/Coding EMS Burns 92

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 EKG/ECG Wellness 52

American Medical Compliance

JUNE 24, 2024

Within this training, we will explore the understanding of skin conditions regarding elderly patients, plan of action in case a skin breakout occurs, identify residents who are vulnerable to certain skin conditions, and how accurate documentation is crucial in keeping patients healthy.

Documentation/Coding 52

Documentation/Coding Outcomes 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 97

Documentation/Coding EMS Operations Emergency Department 97

Stop and Think

JULY 17, 2024

Reading only the guidelines is not enough, because guideline documents are merely one group’s take of the seminal trials. I often advise young learners to break away from, say, learning how to measure the left atrial appendage, and spend some time reading the seminal trials.

Wellness 65

Wellness Documentation/Coding Academics 65

Northwestern EM Blog

JULY 22, 2024

Tandlich, M. 2024, Jul 22).Posterior Posterior Reversible Encephalopathy Syndrome (PRES) [NUEM Blog.

Seizures 81

Seizures Documentation/Coding Hospitals 81

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 59

Documentation/Coding Emergency Department 59

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 68

Documentation/Coding EMS Stroke Patient Safety 68

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

Ken Grauer, MD

JUNE 22, 2024

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". KEY Point: The respiratory rate that is written on the chart does not count!

EKG/ECG 420

EKG/ECG Documentation/Coding Stroke Wellness 420

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 95

Documentation/Coding Wellness EKG/ECG Hospitals 95

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

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 139

Pediatrics Documentation/Coding Burns Academics 139

American Medical Compliance

JUNE 28, 2024

Languages: American English Key features: Audio narration, learning activity, and post-assessment.

Teamwork 96

Teamwork Documentation/Coding Outcomes 96

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

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

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

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

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