Course 6: Billing Flashcards
Discharged Home (DC’D): Document (5)
- Follow-up
- Time period in which to follow-up.
- Specific conditions for return to the ED (specific emergency sx to return for)
- “Stable for discharge”.
- Time of disposition
Admitted: Document (5)
- Admitting physician: ED physician will consult another physician to admit.
- Patient condition: physician will give “good, fair, serious, critical.”
- Time of consult with admitting physician
- Admission location- where transported to (which section of hospital)
- Admission time
Transferred: Document (4)
- “Patient stable for transfer.”
- Time of consult with accepting facility: document TIME and NAME of person spoken to, NAME of accepting physician, and “they will accept this pt in transfer”.
- “ED records accompanying pt”: ED records sent with pt, i.e. your chart needs to be done.
- “Appropriate mode of transfer arranged.”
Level 5 Care Elements
HPI= 4 elements
ROS= 10 elements
PMH/SH/FH=2 elements
PE = 8 elements
Level 5 HPI
4 Elements:
location, quality, timing, severity, duration, assoc sx, modifying factors, context
Level 5 ROS
10 Elements: Const. Eyes ENT Cardiovascular Respiratory GI GU Musculoskeletal Neurological Integumentary Hematological Lymphatic Immunological Psychological
-OR- 2 Elements and “all systems neg”
Level 5 PMHx
2 Elements:
Past Medical/Surgical Hx
Social Hx
Family Hx
Level 5 PE
8 Elements (or 8 dif organ systems) Const. Eyes ENT Cardiovascular Respiratory GI GU Musculoskeletal Neurological Integumentary Hematological Lymphatic Immunological Psychological
Caveats to the Level 5 Elements (6)
Respiratory Distress Unresponsiveness Clinical condition Dementia AMS Limited cognitive ability
“Unable to obtain a complete __ due to __” in EACH section independently.
Level 5 MDM
Old records ordered and results lab and radiology orders and results consults discussions with pt/family multiple DDx Multiple final Dx References to lab/rad results meds and treatments in the ED multiple re-evals arranging follow-up discussion of specific risks
Additional Documentation: CCT
Min of 30 min
Additional Documentation: Pulse Ox Interpretation
Normal or hypoxic
Additional Documentation: Xray interpretation
Record # OF VIEWS, as well as “interpreted by EP”.
Include 3 findings.
Additional Documentation: EKG Interpretation
Must have RATE, RHYTHM, and 2 OTHER FINDINGS
Additional Documentation: ED Procedures
Commonly missed are Splint applications, laceration repairs, bedside ultrasounds, and foreign body removals
Abnormal Vital Signs for CCT
HR: Normal 60-100 ; Abnormal 120 (Adults)
BP: Normal 90/60 - 140/90 ; Abnormal less than 80/– or greater than 180/–
O2 Sat: Normal 96% + on RA ; Abnormal less than 90%
T: Normal 97 to 99. Fever is greater than 100.4 F. ; Abnormal 104
Common O2 Routes (4)
- Room Air (RA)
- Nasal Cannula (NC) - usually 2 LPM (liters per min)
- Facial Mask (FM) - set from 6 to 15 LPM
- Non-rebreather mask (NRB): reservoir bag attached, 10-15 LPM
CCT O2 Routes (4)
- Continuous Positive Airway Pressure (CPAP)
- Biphasic Positive Airway Pressure (BiPAP)
- Bag-Valve-Mask (BVM)
- Endotracheal Tube (ETT)
Core Measure: Acute MI
“Aspirin 324 mg given at arrival”
Core Measure: Chest Pain (non-traum)
“12-Lead EKG performed in ED”
Core Measure: Syncope
“12-Lead EKG performed in ED”
Core Measure: CVA
Document “Last Known Well” date and time.
Document tPA eligibility (within 3 hours of onset).
Core Measure: PNA
Document vital signs, O2 Sat, Mental Status
Document abs selection and timing
Document BCx
Core Measure: Acute PE
“Anticoagulation (heparin) ordered.”
Core Measure: Acute Otitis Externa
“Topical therapy.
Pain assessment.
Avoidance of PO (systemic) abx”
Core Measure: Abdominal Pain- Female Pt
“Pregnancy test (uHCG) was ordered.”
Core Measure: Pregnant Abdominal Pain
“US was ordered to determine the location of the pregnancy (r/o ectopic).”
Core Measure: Pregnant and Rh Neg
“Rhogam was ordered.”
Core Measure: Central Line Placement
“Sterile technique: cap, mask, sterile gown, sterile gloves, sterile sheet, hand hygiene, 2% chlorohexidine”
