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
