Diagnoses, Dispositions, and Billing

Question 1

The final diagnosis is the culmination of the entire ED workup.

TRUE or False

Answer 1

TRUE

Question 2

Each diagnosis becomes a permanent part of the patient’s medical history.

TRUE or FALSE

Answer 2

TRUE

Question 3

What are the three types of dispositions?

Answer 3

Home

Transfer

Admit

Question 4

How many elements are requried in HPI to reach a level 5?

Answer 4

4

Question 5

How many elements are requried in ROS to reach a level 5?

Answer 5

10

Question 6

How many elements are requried in PMHx, PSHx/FHx/SHx to reach a level 5?

Answer 6

2

Question 7

How many elements are requried in PE to reach a level 5?

Answer 7

8

Question 8

If any part of the patient care is not documented then the physician cannot legally reimbursed for their time or expertise.

TRUE or FALSE

Answer 8

TRUE

Question 9

Your family member was recently seen in the ED last week and had blood cultures taken. As a scribe, you can look up their medical information and pending results.

TRUE or FALSE

Answer 9

FALSE

Question 10

Core Measures

Answer 10

a national standard of care for emergency physicians

The 10 diagnoses are MI, Chest Pain, Syncope, CVA, PNA, PE, Female Abdominal Pain, Pregnant Abd Pain/Vag bleeding, and Acute Otitis Externa (outer ear infections).
A central Line is the only procedure with an associated Core Measure

Question 11

Protected Health Information

Answer 11

anything related to the pt

Question 12

Follow up physician

Answer 12

the pt will always be told who to follow up with. make sure you include this in your chart. it is often their PCP, a local clinic or specialist

Question 13

Time period in which to follow up

Answer 13

important to document how many days until the pt should follow up

Question 14

Specific conditions for return to the ED

Answer 14

always include the specific symptoms for which the patient should immediately return to the ED. MOST IMPORTANT

Question 15

Stable for discharge

Answer 15

this should be documented on every pt being discharged.

Question 16

TIme of disposition

Answer 16

remember to timestamp and if they are receiving someting before they are leaving note this

Question 17

admitting physician

Answer 17

emergency physicians do not admit pts directly so thye will always consult another physician to admit

Question 18

patient condition

Answer 18

physician will provide you with the clinical condition of the pt.

Question 19

time of consult with admitting physician

Answer 19

timestamp when your physician speaks with the consult physician that is agreeing to admit the pt

Question 20

patient stable for transfer

Answer 20

under EMTALA a patient may only be transferred if their condition is stable enough that they will not deteriorate on their way to the new facility

Question 21

time of consult with accepting facility

Answer 21

document the time and name of the person with whom your physician spoke to arrange the transfer

Question 22

ED records accompanying patient

Answer 22

the ED records must be sent to the new facility along with the pt

Question 23

Appropriate mode of transfer arranged

Answer 23

must decide what the best way to transfer the patient is

Question 24

Goal as a Scribe

Answer 24

eliminate all down coded charts

Question 25

HPI elements

Answer 25

location quality timing severity duration associated signs and symptoms modifying factors context

Question 26

ROS and PE elements

Answer 26

constitutional EENTM Cardiovascular Respiratory GI GU MS Neurological Integumentary Hematologic/Lymphatic Allergic/Immunologic Psychiatric

Question 27

Past HIstory Elements

Answer 27

PMHx PSHx Sx FHx

Question 28

Evaluation may be limited secondary to

Answer 28

repiratory distress unresponsive clinical condition dementia AMS limited cognitive ability vague/poor historian

Question 29

Level 5 Medical Decison Making

Answer 29

old records ordered and reviewed lab and radiology orders and results consultations discussions with patients/family multiple different diagnoses multiple final diagnoses references to lab/rad results medications and treatments in ED arranging follow up discussion of specific risks

Question 30

Physician may be reimbursed

Answer 30

critical care time: 30 min or more pulse ox interpretation: normal or hypoxic x-ray interpretation EKG interpretation: must have the rate, rhythm, and at least two other findings ED procedures: commonly missed ones include splint applications, laceration repairs, bedside US, and foreign body removal

Question 31

Physical quality reporting initiative

Answer 31

Acute MI: aspirin 324 mg Chest Pain: 12 lead EKG performed in ED Syncope: 12 lead EKG performed in Ed CVA/TIA: last known well date and time, document tPA eligibilty Pneumonia: vital signs, O2 saturation, mental status,antibiotic selection and timing, blood cultures Acute PE: anticoagulation (heparin) ordered Acute Ottis Externa: topical therapy, pain assessment, avoidance of PO antibiotics Abdominal pain-female: pregnancy test (uHCG) Pregnant abdominal pain or prenancy: US Pregnant and Rh negative: Rhogam was ordered Central line placement: sterile technique: cap, mask, sterile gown, gloves, 2% chlorohexidine

Question 32

Room Air

Answer 32

this means the patient is not on oxygen, they are breathing the air in the room like everyone else

Question 33

Nasal Cannula

Answer 33

a plastic tube placed into the patient’s nostrils. It typically delivers oxygen at 2 LPM (liters per minute), although it may be set from 1 to 6 LPM.

Question 34

Facial Mask

Answer 34

a plastic mask fit over the nose and mouth, set from 6 to 15 LPM

Question 35

Non-rebreather mask

Answer 35

a facial mask with a reservoir bag attached. Delivers 10 to 15 LPM

Question 36

Continuous positive airway pressure (CPAP)

Answer 36

a large mask is strapped to the patient’s face, delivering continuous air pressure.

Question 37

Biphasic positive airway pressure (BiPAP)

Answer 37

a large mask is strapped to the patient’s face and the machine alternates pushing air in and letting it out

Question 38

Bag-valve-mask

Answer 38

a large facial mask held in place by hand and attached to an Ambu-bag used to manually inflate the patient’s lungs

Question 39

Endotracheal tube (ETT)

Answer 39

placed by endotracheal intubation, an ET tube goes through the patient’s mouth and down the trachea. It is used if the pt is experiencing respiratory failure and is unable to breath on their own. It is also sometimes used to “protect the patient’s airway” to ensure that a patient does not aspirate (inhale vomit). ET tubes are typically attached to an Ambu-bag temporarily, until they can be attached to a ventilator (breathing machine).