The Trauma Pro

MAY 9, 2025

Ive simplified the calculation process even more and provided a Microsoft Word document that automates the task for you. If so, you may need to add a new activation criterion. Then, count that patient as undertriage, of course. Just download the file, fill in four values in the table, update the formulas, and youve got your numbers!

Documentation/Coding 147

Documentation/Coding 147

The Trauma Pro

JUNE 28, 2024

Work not documented is work not done” This is my quote and it’s one of my favorites. Accurate, complete, timely, and legible documentation is a must! Documentation, or lack thereof, will not get you sued. Documentation, or lack thereof, will not get you sued. And providing a date and time is absolutely critical.

Documentation/Coding 202

Documentation/Coding 202

Mount Sinai EM

AUGUST 7, 2024

Evidence of right heart strain is important but the evidence of fibrinolysis during arrest is mixed with many studies showing no 30-day mortality benefit to lysing during a code. Rapidly intervened-upon cardiac tamponade in PEA during cardiac arrest has significantly higher hospital discharge rates. survival to hospital discharge rate.

Ultrasounds 235

Ultrasounds CPR Documentation/Coding COPD 235

EM Ottawa

NOVEMBER 30, 2023

Sunita Puir, a palliative care doctor, talks about how it is an “open secret in medicine that CPR is brutal and rarely effective,” yet how the public seems […] The post Decoding Code Status: A Goals of Care Framework appeared first on EMOttawa Blog.

Documentation/Coding 83

Documentation/Coding CPR Resuscitation 83

PulmCCM

FEBRUARY 5, 2025

A new meta-analysis challenges that dogma , and makes an already challenging decision-making process even thornier for neurologists answering “code strokes” At least 8 randomized trials have been published testing IV thrombolytics given more than 4.5 hours after stroke symptom onset.

Stroke 101

Stroke Documentation/Coding Outcomes 101

American Medical Compliance

JUNE 21, 2024

Here are key areas where they can make a significant impact. Accurate Documentation and Coding Accurate documentation and coding are fundamental in preventing fraud, waste, and abuse. This includes segregation of duties, regular audits, and having checks and balances in billing and coding processes.

Documentation/Coding 105

Documentation/Coding Leadership Best Practices Outcomes 105

ACEP Now

MARCH 10, 2025

ACEP has summarized these issues in its Code of Ethics: Emergency physicians shall communicate truthfully with patients and secure their informed consent for treatment, unless the urgency of the patients conditions demands an immediate response. American College of Emergency Physicians: Code of Ethics for Emergency Physicians.

Documentation/Coding 52

Documentation/Coding Emergency Department Psychiatric Risk Management 52

Dr. Smith's ECG Blog

NOVEMBER 25, 2024

The guide is a living document, which I (Willy Frick) will continuously update as I encounter additional angiographic images worth learning from. Attaining expertise in angiography requires dedication and practice. What follows is an introduction to angiography -- a guide meant for people with no prior experience interpreting angiograms.

Documentation/Coding 120

Documentation/Coding EKG/ECG 120

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. Bottom line: A uniform “code of behavior” is essential! Click here to download a sample Trauma Services consultant guidelines document.

Documentation/Coding 113

Documentation/Coding Best Practices 113

EM Ottawa

APRIL 24, 2025

In this section, we focus on risk assessment, documentation, and advice from lawyers and CMPA experts, with some frequently asked questions to conclude. In part 1 of this 2-part series on medicolegal risk in Emergency Medicine, we looked at two legal cases, with a primary focus on civil litigation and college complaints.

Documentation/Coding 76

Documentation/Coding Wellness Hospitals 76

Sensible Medicine

OCTOBER 19, 2023

We wrote this letter and submitted it to the journal, documenting that the trial violated ethical codes. Kids are a vulnerable population— subject to teasing and bullying— and frankly the dogs were not that good at sniffing COVID19. Lots of false positives and negatives. Yet the journal refuses to print it.

Documentation/Coding 133

Documentation/Coding Pediatrics Research Outcomes 133

Emergency Medicine Journal

APRIL 22, 2025

Background Standardised consensus-based documentation following anterior shoulder dislocation in the ED might improve clinical quality, reduce heterogeneity in research and reduce workload. The aim of this study was to determine important elements and the extent of variability for the ED documentation following anterior shoulder dislocation.

Dislocations 52

Dislocations Documentation/Coding Research Outcomes 52

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. Microvascular dysfunction — cardiac vasculitis — intravascular thrombosis.

EKG/ECG 195

EKG/ECG Documentation/Coding Sepsis COPD 195

Dr. Smith's ECG Blog

NOVEMBER 27, 2023

Written by Jesse McLaren A 45 year old presented with two weeks of recurring non-exertional chest pain, now constant for an hour. Below is old and then new ECG (old on top; new below). What do you think? Both ECGs have normal sinus rhythm, normal conduction and normal voltages.

EKG/ECG 111

EKG/ECG Documentation/Coding Wellness 111

Emergency Live

DECEMBER 21, 2023

The Importance of Color Codes in Hospital Emergency Situations and on Rescue Vehicles Color Codes in Hospital Emergencies In hospital settings, color codes are used to communicate specific emergency situations quickly and effectively.

Documentation/Coding 105

Documentation/Coding Hospitals 105

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 433

EKG/ECG Stroke Documentation/Coding Wellness 433

EM Literature of Note

JANUARY 16, 2025

There are going to be issues with confounding, mis-coded data, and variation across sites. The general implication vilifying those clinicians with higher rates of admission, as these behaviors are generating only short (read: unnecessary) admissions of no value (no mortality difference).

Outcomes 77

Outcomes Radiology Radiology Emergency Department 77

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. State regulations and codes may place that responsibility on our shoulders.

Documentation/Coding 96

Documentation/Coding Patient Safety Emergency Department Hospitals 96

Pediatric EM Morsels

OCTOBER 27, 2023

He, along with Dr. Bob Luten, a PEM physician in Jacksonville, FL , designed the Broselow-Luten color-coded length-based system to help estimate a child’s weight, and thereby offload the cognitive burden of medication dosing and choice of equipment sizes in pediatric resuscitations. .”

Pediatrics 274

Pediatrics Resuscitation Documentation/Coding Wellness 274

EMDocs

APRIL 3, 2025

It’s 1 cc of code dose epi in a 10-cc syringe of NS. Replace that 1 cc of NS with 1 cc from the code dose epi box. Also, before I go back to my drugs, remember, push dose epi can help you if you’re in a pinch. Squirt out 1 cc from the saline syringe. That makes a syringe of 10 mcg of epi per ml.

EKG/ECG 94

EKG/ECG Documentation/Coding Wellness EMS 94

Mind The Bleep

FEBRUARY 2, 2025

Your response may range from simply documenting the event somewhere secure, so that you have a contemporaneous record of what happened and who else may have been involved to support any future decisions you might make, all the way up to formally speaking up. It is hard to speak up sometimes.

Documentation/Coding 98

Documentation/Coding Outcomes Burns Wellness 98

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 143

Documentation/Coding 143

The Trauma Pro

JULY 5, 2024

The emergency physician should be sure to convey their concerns very clearly, tell the specialist that the conversation will be documented carefully, and then do so. Be sure to fill out a consent as soon as practical, and document any attempts that were made to obtain it. Make sure all is documented well on the consent or in the EHR.

Documentation/Coding 113

Documentation/Coding Fractures Emergency Department Wellness 113

Sensible Medicine

OCTOBER 19, 2023

We wrote this letter and submitted it to the journal, documenting that the trial violated ethical codes. Kids are a vulnerable population— subject to teasing and bullying— and frankly the dogs were not that good at sniffing COVID19. Lots of false positives and negatives. Yet the journal refuses to print it.

Documentation/Coding 94

Documentation/Coding Pediatrics Research Outcomes 94

EMDocs

APRIL 2, 2024

Check the pulse RSI= Resuscitation Sequence Intubation Hypoxia, Hypotension, and Acidosis are the reason patients code during/post intubation These patients are super high risk for all 4 Optimize first pass success – Induction agent + paralytic Unconscious patients will still have muscle tone Induction Ketamine or Etomidate at half doses (i.e.,

Documentation/Coding 113

Documentation/Coding CPR EKG/ECG Sepsis 113

University of Maryland Department of Emergency Med

NOVEMBER 2, 2023

BACKGROUND: Prehospital (EMS) clinicians are positioned on the front lines of health care. With respect to stroke identification and treatment, ea. Click to view the rest

Stroke 64

Stroke Documentation/Coding EMS 64

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 Emergency Department 130

PEMBlog

NOVEMBER 21, 2024

Deb Hsu, MD, MEd – Division Director, Stanford Documenting feedback: Facilitate trainee growth and ensure program accreditation Discussed structuring feedback to ensure trainees and faculty receive actionable insights for growth while providing programs with documented evidence of this feedback to meet accreditation requirements.

Documentation/Coding 52

Documentation/Coding Pediatrics Emergency Department 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. Passively, I watch another clinician’s cursory examination of a critically ill patient to determine how they deem a patient “toxic-appearing” or their bedside neurological assessment to activate a code stroke.

Emergency Department 59

Emergency Department Mass Casualty Incidents Documentation/Coding Sepsis 59

Sensible Medicine

AUGUST 3, 2024

These participants received a gift card code in this email so they could purchase a 50-pack of masks at their local pharmacy. To reiterate, the intervention was an email with instructions and a gift code. Half of the participants were instructed to wear masks when out in public. What was the outcome? The outcome was not illness.

Documentation/Coding 145

Documentation/Coding Outcomes Research 145

Sensible Medicine

AUGUST 17, 2024

Spending day and night coding. Think about the tech bro in a dirty, drafty San Francisco house, sleeping on a mattress on the floor, drinking Nespresso, and coding all day, and consider perhaps that what you are doing might not be any better… except with less upside. One day, we were having coffee, and she mused.

Documentation/Coding 127

Documentation/Coding Research Burns 127

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 120

EKG/ECG Documentation/Coding Emergency Department Outcomes 120

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

Dr. Smith's ECG Blog

JUNE 7, 2024

The discharge diagnosis was STEMI based on the STEMI positive ECG and code STEMI activation, with culprit lesion on angiography. Despite this clinical reality — all too many clinicians still fail to document the presence and relative severity of CP at the time each serial ECG is recorded.

EKG/ECG 113

EKG/ECG Documentation/Coding EMS Outcomes 113

Emergency Live

APRIL 26, 2024

It’s a special nitrogen-containing compound that pairs with adenine, cytosine, and thymine (or uracil in RNA) to form the genetic code. One of the four main building blocks of DNA and RNA is guanine. What makes guanine unique is its […] The post The Essential Role of Guanine in DNA and RNA appeared first on Emergency Live.

Documentation/Coding 98

Documentation/Coding 98

PulmCCM

SEPTEMBER 17, 2023

Fully implemented, CDC’s toolkit would promote sepsis into the major leagues of “code strokes” and “code STEMIs” — highly prioritized system-wide operational programs enjoying executive sponsorship and significant financial and human resources.

CDC 98

CDC Sepsis Hospitals Documentation/Coding 98

PDC Healthcare

JANUARY 16, 2023

Thousands of healthcare facilities across the country have adopted standardized, color-coded alert wristbands […]. Being able to easily differentiate and identify these risks can be the difference in ensuring a patient’s safety and makes fulfilling a patient’s needs easier for healthcare workers.

Documentation/Coding 98

Documentation/Coding Patient Safety 98