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
Syncope Core Measure
12-Lead EKG performed in ED
Ischemic CVA Core Measure
Document “last known well” date and time
Document tPA eligibility (w/in last 3 hours of onset)
Pneumonia
Vital signs, O2 sat, mental status
Abx, selection and timing
Blood cultures
Acute PE
Anticoagulation offered
HIPPA
Health Insurance Portability and Accountability Act
PHI
Protected Health Information
HITECH
Health Information Technology for Economic and Clinical Health
