Day 6 Review Flashcards
1
Q
What must you doc when a Pt is transferred?
A
“Pt stable for transfer”, time of consult with accepting facility (time and name of consulted Physician; “they will accept this Pt in transfer”), ED records accompanying Pt, “appropriate mode of transfer arranged”
2
Q
AMA
A
Against medical advise
3
Q
What must you doc if Pt is admitted?
A
Admitting Physician (EP will always consult another physician to admit), time of consult with admitting physician (including details of convo), Pt condition (“not stable” if admitted), admission location (Pt transported to another area of hospital), admission time
4
Q
List the minimum score for each section in order to receive a level 5 (HPI, ROS, PMH/SH/FH, PE)
A
HPI: 4
ROS: 10 (2 if “all sys neg” box checked)
PMH/FH/SH: 2
PE: 8
