Day 6: Final Diagnoses

Question 1

For any pt discharged home remember to document:

Answer 1

1. follow up
2. time period in which to follow up
3. specific conditions for return to ED
4. “stable for discharge”
5. Time of dispo

Question 2

For any pt admitted, remember to document:

Answer 2

1. admitting physician
2. patient condition
3. time of consult with admitting physician

Question 3

For any pt transferred remember to document:

Answer 3

1. patient stable to transfer
2. time of consult with accepting facility: include time & name of the person with whom the physician spoke to arrange the transfer; as well as the name of the accepting physician and “they will accept this person in transfer”
3. ED records accompanying patient (finish the chart!)
4. appropriate mode of transfer arranged

Question 4

What laws govern how and when patients may be transferred?

Answer 4

EMTALA

Question 5

Coding level 5 for HPI:

Answer 5

minimum 4 elements

Question 6

Coding level 5 for the ROS:

Answer 6

minimum 10 elements

Question 7

Coding level 5 for PHx

Answer 7

2 minimum elements: PMSHx, SHx, FHx

Question 8

Coding level 5 for PE

Answer 8

8 minimum PE elements

Question 9

Coding level 5 summary:

Answer 9

HPI: 4 (onset, timing, location, quality, severity, modifying factors, etc)
ROS: 10 (or 2 with “all systems negative except as
marked)
PMSFHx: 2 (Pas medical and surgical count as one; must have either social or FHx)
PE: 8 (at least one finding in 8 different organ systems

Question 10

Remember that if a person is unable to give an HPI or ROS then document:

Answer 10

unable to obtain a complete ____ due to ____ so that the chart doesn’t get downcoded

Question 11

Examples of caveats to level 5 coding elements:

Answer 11

respiratory distress, unresponsiveness, clinical condition, dementia, AMS, limited cognitive ability

Question 12

Req for critical care time

Answer 12

minimum of 30 min

Question 13

pulse ox interpretation

Answer 13

normal or hypoxic

Question 14

x-ray interpretation

Answer 14

always record # of views as well as “interpreted by EP”. Include 3 findings, minimum

Question 15

EKG interpretation

Answer 15

must have the rate, rhythm, and at least 2 other findings

Question 16

ED procedures:

Answer 16

commonly missed procedures: splint applications, laceration repairs, bedside US, and foreign body removals

Question 17

Don’t forget to ask the Doc about critical care time. Common critical care diagnoses include:

Answer 17

MI, PE, CHF, CVA, AFIB w/RVR, PTX, appendicitis (w/rupture), GI bleed, Sepsis, Severe AMS, Meningitis, DKA, acute renal failure, severely abnormal vital signs

Question 18

Common critical care procedures:

Answer 18

Intubation, Chest tube, central line, CPR, cardioversion, and CPAP/BiPAP

Question 19

What is a severely abnormal HR?

Answer 19

less than 50 bpm or over 120 bpm in adults

Question 20

What is a severely abnormal BP?

Answer 20

less than 80/– or above 180/–

Question 21

WHat is a severely abnormal O2 sat?

Answer 21

less than 90% on room air

Question 22

What is a severely abnormal temp?

Answer 22

less than 95 or more than 104 F

Question 23

Common O2 routes (4)

Answer 23

1. Room Air (RA)
2. Nasal Cannula (NC) usually 2 LPM (1-6)
3. Facial Mask (FM) (6-15 LPM)
4. Non-Rebreather Mask (NRB) (10-15 LPM)

Question 24

Critical Care O2 Routes (4)

Answer 24

1. CPAP: continuous positive airway pressure
2. BiPAP: Piphasic Positive Airway Pressure
3. Bag-Valve-Mask (BVM)
4. ETT: endotracheal tube

Question 25

Core measures (15)

Answer 25

1. acute MI
2. CP
3. central line placment
4. female abdominal pain
5. hospital-acquired conditions
6. ischemic CVA
7. long bone fracture
8. otitis externa
9. PNA
10. pregnant: abd pain
11. pregnant: and Rh neg
12. pregnant: vaginal bleeding
13. PE
14. Syncope
15. 30 day readmission to hospital