American Medical Compliance

FEBRUARY 17, 2024

With the Occupational Safety and Health Administration (OSHA) setting standards to protect workers from occupational hazards, healthcare organizations face unique challenges in maintaining compliance due to the complexity of their operations and the diverse array of risks inherent in patient care.

Best Practices 105

Best Practices PPE Infectious Diseases Documentation/Coding 105

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

ACEP Now

JUNE 7, 2023

ED leaders worked to develop new physician documentation and coding guidelines that needed to be implemented at the beginning of 2023. Software attacks crippled operations in large hospital chains, and physical assaults on ED staff continued unabated. Executive Summary of ED Operations in 2022 Volume was up from 2021.

Emergency Department 52

Emergency Department Documentation/Coding Operations EMS 52

PulmCCM

MARCH 11, 2024

About 544,000 99292 codes were billed to CMS in 2021, according to ACCP , reportedly stable at about 10% of the total bills. Ascension is a $27 billion, 140-hospital conglomerate operating in 19 states—the third largest system in the U.S The other new signal is in corporate health care operations: One of the largest U.S.

Hospice 52

Hospice Documentation/Coding Administration Hospitals 52

EM Literature of Note

OCTOBER 1, 2023

” This brief report in Annals describes a retrospective experiment in which 30 written case summaries lifted from the electronic documentation system were fed to either clinician teams or ChatGPT. Prior to ChatGPT, clinicians did not operate in an information resource vacuum, as is frequently the case in these contrived situations.

Documentation/Coding 97

Documentation/Coding Operations Emergency Department Wellness 97

EB Medicine

NOVEMBER 1, 2021

Also, this month use code ACEP21! It is in Beta and your feedback is welcome. ,* Also, this month use code ACEP21! EMplify – November 2021 Announcements: The EB Medicine app is live and available for free in the Apple Store. Coming to Google Play soon. It is in Beta and your feedback is welcome. Coming to Google Play soon.

Fractures 52

Fractures Documentation/Coding Operations Emergency Department 52

The Skeptics' Guide to EM

MAY 11, 2019

Background: The first documented appendectomy was done by Claudius Amyand in 1735. This is an example of why things in evidence-based medicine can be “complicated” ( SGEM#115 and SGEM#180 Clinical Question: Operative treatment or non-operative treatment of acute Grade 1 (uncomplicated) appendicitis? Reference: Sceats et al.

Documentation/Coding 52

Documentation/Coding Operations Academics Ultrasounds 52

ACEP Now

NOVEMBER 14, 2023

In 1901, UVA opened its first hospital with 25 beds and three operating rooms. The emergency department (ED) at UVA was rebuilt in 2019 and the department had not fully optimized its operations when COVID-19 hit. They also developed standard work documents for each role.

Academics 52

Academics Emergency Department Leadership Operations 52

American Medical Compliance

SEPTEMBER 10, 2023

The patient must be competent to decide voluntarily whether to undergo the operation or intervention. 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?

Blood Transfusions 52

Blood Transfusions Documentation/Coding Operations 52

Taming the SRU

MAY 11, 2024

Usually presents consistent with failure of that organ. For mid-shaft femur fractures, traction appears to may reduce blood loss and pulmonary complications, but the available data is very scarce.

Administration 81

Administration Resuscitation Research Fluid Resuscitation 81

ACEP Now

NOVEMBER 7, 2023

3 These regulations have led to widespread practices of EHI, such as test results and clinical documentation, being shared with patients in real time. Training opportunities for documentation best practices should be employed. Code of federal regulations eCFR website. substance use disorder” rather than “drug addict”).

Documentation/Coding 52

Documentation/Coding Best Practices Ethical Issues Academics 52

PulmCCM

FEBRUARY 5, 2024

You can read the document here. Read the original document here. Recall the panel also recommended abdominal CT earlier in the guideline for postoperative patients, and acknowledges CT might be the better first test (rather than ultrasound) in at least some post-op and non-operative critically ill patients. What’s a Fever?

Best Practices 111

Best Practices Ultrasounds Infectious Diseases Sepsis 111

PulmCCM

JUNE 5, 2023

Check out the preliminary program , and use code PULMCCM15 to get 15% off the attendance fees. Most health systems haven’t done the operations work (including paying for people and technology) to build robust screening programs, and physicians haven’t been pushing hard for it either. Rochelle Walensky steps down this month.

Advances Cardiac Life Support (ACLS) 96

Advances Cardiac Life Support (ACLS) Documentation/Coding CPR Shock 96

Mind The Bleep

MAY 1, 2024

Appropriate first line management will help protect and resuscitate the soft tissues and keep the fracture still either to allow healing or until definitive management (operative fixation) is possible. The soft tissues are also damaged. Reduce, Hold, Rehabilitate Reduce The aim is to restore anatomical alignment.

Fractures 52

Fractures Documentation/Coding Head Injuries Dislocations 52

Don't Forget the Bubbles

MAY 10, 2023

Then you hear the words coming out of the speaker, “ Paediatric code black. Paediatric code black ”. You’ve heard the phrase code black before – it’s a traumatic cardiac arrest. You know a paediatric code black means paediatric traumatic cardiac arrest. Then the patient is rapidly moved to the operating theatre.

Emergency Department 91

Emergency Department Resuscitation Documentation/Coding Teamwork 91

ACEP Now

MARCH 13, 2024

Consequences of this are well documented and include delayed treatment, exposure to error, increased length of stay, and increased mortality. Conclusion/Recommendation ED crowding is a national patient safety issue driven by hospitals routinely operating over capacity. ED crowding impairs this mission. Click to enlarge.

Ethical Issues 52

Ethical Issues Emergency Department Operations Hospitals 52

Medical Law

FEBRUARY 4, 2021

Vehicle Code Section 312.5(1)-(3)). Vehicle Code Section 312.5(c)). Vehicle Code Sections 21200 et seq ). Vehicle Code Section 21212). For example, all E-bike operators need to be 16 years or older and all Class 3 riders must wear a helmet regardless of age. Vehicle Code Section 21213).

Documentation/Coding 52

Documentation/Coding Legal Issues Operations 52

Total Medical ComplianceHIPAA

JANUARY 12, 2023

During those two years, the OCR oversees all compliance activities and requires that all HIPAA related documentation and issues be submitted and approved or reported to them according to strict guidelines. Many comments to the NPRM noted that this would be an operational and compliance risk issue for providers.

Operations 104

Operations Best Practices Documentation/Coding Administration 104

The Skeptics' Guide to EM

JULY 30, 2022

Background: Somewhere between two and four percent of patients presenting to US EDs with abdominal pain have a small bowel obstruction (SBO) – those who are managed operatively (who are only 20-30%) account for 60,000 hospitalizations and 565,000 inpatient care days per year. Also joining us is Dr. Andrew Goldsmith.

Ultrasounds 52

Ultrasounds Operations Outcomes Documentation/Coding 52

Total Medical ComplianceHIPAA

NOVEMBER 29, 2021

Documentation or other confirmation of vaccination, however, must be kept confidential and stored separately from the employee’s personnel files under Title I of the Americans with Disabilities Act (ADA).

Documentation/Coding 52

Documentation/Coding Operations 52

Ziqitza HealthCare Ltd

JUNE 18, 2023

Streamlining Administrative Tasks: Improving Efficiency and Reducing Costs AI can automate administrative tasks, such as appointment scheduling, billing, and medical coding, freeing up healthcare professionals’ time and reducing administrative burdens.

Documentation/Coding 52

Documentation/Coding Administration Ambulance Services Outcomes 52

American Medical Compliance

MARCH 15, 2024

While EHRs offer numerous benefits, including improved documentation and care coordination, they also introduce complexities and potential vulnerabilities. Potential Vulnerabilities of EHRs Moreover, the proliferation of electronic health records (EHRs) presents both opportunities and challenges for FWA compliance.

Best Practices 105

Best Practices Risk Management Documentation/Coding Operations 105

Total Medical ComplianceHIPAA

NOVEMBER 29, 2021

Documentation or other confirmation of vaccination, however, must be kept confidential and stored separately from the employee’s personnel files under Title I of the Americans with Disabilities Act (ADA).

Documentation/Coding 40

Documentation/Coding Operations 40

Medical Law

DECEMBER 28, 2023

In California, you are allowed to operate a dashcam while driving along public roads, as there is no expectation of privacy. Dashcams continue to grow in popularity as the technology improves and prices lower. They are now a standard feature in many new vehicles. Dashcam laws vary from state to state.

Legal Issues 52

Legal Issues Documentation/Coding Operations 52

Advanced Medical Reviews

FEBRUARY 13, 2019

Physicians who reported marginal time for documentation were 2.8 Many physicians often have too little time for documentation, utilize non-intuitive EHR user interfaces and have either not enough or too much data. Clinical information and documentation are all streamlined through our web interface.

Documentation/Coding 64

Documentation/Coding Administration Operations Research 64

Taming the SRU

SEPTEMBER 1, 2023

to divert the plane).

Sepsis 84

Sepsis Administration Documentation/Coding Fractures 84

ACEP Now

MARCH 14, 2024

In our case, the patient had a CT of the head, cervical spine, and chest, abdomen, and pelvis with intravenous contrast demonstrated a C2, C7 compression fracture with significant bowel edema (Figure 4), and was taken to the operating room for left arm disarticulation, left below knee amputation and right above knee amputation. Am J Cardiol.

Burns 52

Burns Fluid Resuscitation EKG/ECG Operations 52

Medical Law

FEBRUARY 13, 2023

AB 1909 alters laws regarding e-bikes and where they are allowed to operate. Peace officers will also be required to document the reason for all traffic stops. AB 2773 requires peace officers to inform drivers why they are being pulled over. AB 2147 limits the circumstances when a pedestrian can be stopped for jaywalking.

Documentation/Coding 52

Documentation/Coding Operations 52

American Medical Compliance

FEBRUARY 15, 2023

Even organized crime groups infiltrate the Medicare Program and operate as Medicare providers and suppliers. Documentation of this distribution is required. Trust is core to the provider-patient relationship. Fraud schemes range from solo ventures to widespread activities of an institution or group.

Administration 52

Administration Documentation/Coding Operations 52

American Medical Compliance

FEBRUARY 15, 2023

Even organized crime groups infiltrate the Medicare Program and operate as Medicare providers and suppliers. Documentation of this distribution is required. Trust is core to the provider-patient relationship. Fraud schemes range from solo ventures to widespread activities of an institution or group.

EMS 52

EMS Administration Documentation/Coding Operations 52

Mind The Bleep

MARCH 22, 2023

Antibiotics Obtain IV access and give prophylactic IV antibiotics as soon as possible, ideally within 1 hour of injury The type of antibiotic depends on local hospital/trust protocol Tetanus prophylaxis should also be provided Pre-Reduction Examination Assess neurological and vascular status at repeated intervals A PR or PV exam is mandatory in assessing (..)

Fractures 59

Fractures Documentation/Coding Operations Hospitals 59

Advanced Emergency Nursing from AENJ

AUGUST 2, 2016

" [Coroners Society] King Richard I (the Lionheart) needed vast sums of money for the Third Crusade, operation of the kingdom, and for his ransom fro m Duke Leopold of Austria. All efforts to identify the decedent by hospital staff, law enforcement agencies or social service agencies should be well documented in the medical records.

Documentation/Coding 40

Documentation/Coding Forensics CDC Fractures 40

The Skeptics' Guide to EM

NOVEMBER 21, 2020

The American College of Emergency Physicians ( ACEP ) has a number of documents discussing APPs in the ED. Clinical Question: How does the productivity of advanced practice providers compare to emergency physicians and what is its impact on emergency department operations? Reference: Pines et al. AEM November 2020.

Emergency Department 52

Emergency Department Telemedicine Academics Outcomes 52

Don't Forget the Bubbles

JANUARY 1, 2024

However, children who had an operation experienced improvements in behaviour, symptoms, and quality of life and had lower blood pressure. Point-of-care brain ultrasound and transcranial doppler or color-coded doppler in critically ill neonates and children. They enrolled 459 children aged 3 to 12.9 Pediatrics. Shikha A, et al.

Pediatrics 98

Pediatrics Ultrasounds Blood Transfusions Sepsis 98

PHEM Cast

DECEMBER 12, 2016

pdf Equipment required for resuscitative thoracotomy: Surface anatomy: Appearance of pericardial clot A foley catheter being used to fill a cardiac wound – note how easily this could be pulled out.

Military 52

Military Resuscitation Emergency Department Documentation/Coding 52

ACEP Now

JUNE 6, 2023

A medical student reports a murmur, not documented by either the emergency physician or the cardiologist. POCUS: Point-of-care ultrasound for AD is highly specific, but operator-dependent, and lacking in sensitivity—although late–model units can have sensitivity as high as 80-85 percent. Then what? He denies back pain.

EKG/ECG 85

EKG/ECG Stroke Documentation/Coding Operations 85

Don't Forget the Bubbles

MARCH 11, 2024

Craniosynostosis needs urgent referral and is usually corrected operatively before a child’s first birthday. Recommendations for sudden infant death syndrome prevention: a discussion document. Craniosynostosis can lead to raised intracranial pressure and failure to thrive. and can worsen and become harder to correct over time.

Radiology 59

Radiology Radiology Pediatrics Documentation/Coding 59