Additional Documentation Flashcards
All documentation
- HPI, Physical Exam, Results
- Some Pts require additional documentation
Pulse Ox interpretation
Must add, based on what provider says
ex) 88% on 2L NC. Interpretation: Hypoxic
X-ray interpretation
- record number of views
- write “interpreted by physician”
ex) Three views of the left knee. These reveal moderate degenerative changes, worst in the medial compartment. There is also hardware in the right distal femur. No signs of acute fracture. Interpreted by physician.
EKG interpretations
Must include rate, rhythm, and physician findings
Ex) EKG shows normal sinus rhythm, with a rate of 75 bpm. No acute ST/T changes. No signs of ischemia.
Procedures
If your provider has done something to fix or improve the patient, it should be documented as a procedure. Common procedures include: splint applications (for injured extremities), laceration repairs (stitches or sutures), foreign body removals, and Incision & Drainage (I&D) for abscesses.
Critical care
life-saving
ICD-10 code
Diagnoses are documented as ICD-10 codes
Disposition
Where the patient goes after leaving the emergency department or clinic
3 types:
- admit
- discharge
- transfer
EMERGENCY:
Admit - The patient requires further hospitalization for further treatment, monitoring, or additional testing
Discharge - The patient is not ill enough to benefit from hospitalization (in most cases). They will be discharged to home to follow up with another care provider
Transfer - Any patient that may require specialty care that is not offered at your facility must be transferred to a different hospital. This is a requirement.
OUTPATIENT:
For patients seen in an outpatient clinic, they will often leave the clinic and go home.
Your doctor may recommend they follow up with a specialist or return with any worsening symptoms.
In some cases, your doctor may send patients to the emergency department or admit them directly to the hospital, for further care.
