Dx and Disposition Flashcards
Types of Disposition
Discharged (DC’d), Admitted, Transferred
DC’d documentation
- Follow up
- Time period in which to follow-up
- Specific conditions for return to ED
- Condition: “Stable for discharge”
- Time of disposition
Admitted documentation
- Admitting physician
- Time of consult with admitting physician
- Patient condition
- Admission location
- Admission time
Transfer documentation
- “Patient stable for transfer”
- Time of consult with accepting facility
- “ED records accompanying patient”
- “Appropriate mode of transfer arranged”
E&M/LOS
Evaluation & Management/Levels of Service
HPI Elements Needed for Level 5 Coding
4 Elements
ROS Systems Needed for Level 5 Coding
10 systems or 2 systems + “All systems negative”
PMHx Elements Needed for Level 5 Coding
2 Elements
PE Systems Needed for Level 5 Coding
8 Systems
Loophole
“Unable to obtain complete ____ due to _____” in each section independently (HPI, ROS, PMHx, and PE)
Vital Sign Abnormals
HR - 120
BP - 180/–
SaO2 - Less than 90% on RA
T - 104F
Common O2 Routs
RA - Room Air
NC - Nasal Cannula + O2 % and Amt
FM - Facial Mask + O2% and Amt
NRB - Non-Rebreather Mask + O2% and Amt
Critical Care O2 Routs
CPAP - Continuous Positive Airway Pressure
BiPAP- Biphasic Positive Airway Pressure
BVM - Bag-Valve-Mask
ETT - Endotracheal Tube
Acute MI Core Measure
ASA 324 mg given at arrival
CP (Non-Traumatic) Core Measure
12-Lead EKG performed in ED
