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What are the 4 types of dispositions?
- Discharge
- Admitted
- Transferred
- Against Medical Advice (AMA)
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4 things to document for a Discharge
- time of disposition
- suggested follow up + time period
- specific conditions for return to ED
- “stable for discharge”
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4 things to document for an Admit
- admission location and time
- who the admitting physician is
- time of consult with admitting physician
- condition of pt (good, fair, serious, critical)
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4 things to document for a Transfer
- time of consult w/accepting facility + name of physician
- “pt stable for transfer”
- “ED records accompanying pt”
- “appropriate mode of transfer arranged”
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8 things to document for AMA
- date + time of AMA discussion
- AMA form
- specific risks and benefits of proposed treatment
- pt’s reason for refusal
- consequences of leaving AMA
- self-care instructions
- any outside arrangements (police, social services, relatives)
- pt’s mental capacity
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What is needed for a level 5 chart?
- 4 HPI elements
- 10 organ systems for ROS
- 2 PHx elements
- 8 PE organ systems
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What to document for EKG findings?
- rate
- rhythm
- 2 additional findings
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What to document for X-Ray interpretations?
- at least 3 findings
- “interpreted by EP”
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What is the main goal of ICD-10 documentation?
to be as accurate and specific as possible
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The 4 common oxygen routes
- room air (RA)
- nasal cannula (NC)
- face mask (FM)
- non-rebreather mask (NRB)
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Normal vital signs for Heart Rate?
60-100 bpm
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Normal vital signs for blood pressure?
90/60 - 140/90
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Normal vital signs for oxygen saturation?
96% or above on room air
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Normal vital signs for temperature?
97 - 99 degrees F
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4 Critical care oxygen routes + when they are used
- continuous positive airway pressure (CPAP): delivers cont. air pressure, sleep apnea pt
- biphasic positive airway pressure (BiPAP): machine alternates pushing air in and out
- bag valve mask (BVM): used pre-procedures, manually inflates lungs
- endotracheal tube (ETT): used during respiratory failure
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What is the purpose of MACRA?
- an initiative to cut down healthcare costs
- to switch from volume focus to quality
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Disposition
The patient’s destination after they leave the Emergency Department
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Diagnosis
The process of determining which disease or condition explains a person's symptoms and signs
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Hospitalist
Physician who cares for a hospitalized patient
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E&M Levels
Set of criteria that determine how a physician can be paid for their services
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Level 5
The highest level of billing
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Down-coded
When a physician can only be reimbursed for a lower level of care due to inadequate documentation
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Quality Measure
A national standard among Emergency Physicians that dictates the care and documentation required for each diagnosis or complaint
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Protected Health Information
Any information that can be tied to a particular patient
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HIPAA
A body of laws designed to protect private health information of patients
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HITECH
Privacy laws related to electronic transmission of health information
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