2023

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  • supplemental documentaton:
  • review of external records:
    • discussed with paramedics to obtain collateral.
    • discussed with officers accompanying patientto obtain collateral.
    • reviewed records in emr, and obtained records from a provider outside outside of our group,
      • including review of outpatient primary carenotes,
      • including review of prior discharge hopsitalist note,
  • discussed with consultants:
    • (results of convestation)
    • required communication with radiologist in order to confirm receipt of critical information that impacts patient's care in timely manner,
    • required communication with consultants:
      • hospitalist,
        • in order to communicate clinical information required for admission with inpatient hospitalist
      • cardiologist,
      • surgeon,
      • patient's primary care doctor,
        • communicated via phone,
        • communicated via relay on clinical messaging of chart in emr,
        • in order to ensure coordinated continued care as transition to outpatient basis,
  • considered social determinants of health:
    • housing:
      • housing insecurity,
      • non-domiciled,
    • substance abuse disorder:
      • alochol abuse disorder,
      • illicit substance abuse disorder,
      • currently intoxicated,
    • barriers to access to care:
      • inability to see pmd,
        • given not currently established with pmd and wait times for new patients,
        • given limitations/barriers secondary to insurance related issues,
        • affordability of medications
      • unemployed
        • €‹€‹€‹€‹€‹€‹€‹
  • problems addressed in this visit:
    • ,
  • considered potential utility of additional diagnostics:
    • (general)
      • cxr,
      • ekg,
      • labs,
      • xrs,
      • us,
      • ct,
      • mri,
      • and thought to be in patient's best interest as these diagnostics are unlikely to provide clinical information that would inform patient's care at this time, and with recognition of risks conferred from non-indicated diagnostics.
    • (trauma)
      • risks benefits of imaging, specifically ct
        • head
        • c-spine
        • chest
        • abd / pelvis
        • xrs of extremities
      • and believe these diagnostics confer risks to the patient that outweigh the anticipated benefits.
    • (chest pain)
      • cardiology consultation,
      • observation with serial cardiac enzymes,
        • however felt unlikely to be of utility given
          • heart score,
          • onset of symtpoms sufficiently prior to intiial labs that additional observation and repeat cardiac enzymes unlikely to provide clinically significant benefits.
    • (nausea/vomiting/abdominal complaints)
      • ct a/p but ultimately determined that it was unlikely of diagnostic benefit to the patient and confers risks that were not warranted.
    • (id)
      • chest x-ray, however given the overall well-appearingclinical impression, and with adequate clinical inforamtion that a chest x-ray is unlikely to provide information that will change management.
      • urine analysys, given prevalence of non-clinically significant bacteruria, and given lack of specific symptoms/signs for emergent urinary pathology, urine analysis thought to be likely to confound clinical picture and unlikely to provide overall utility for patient's work up.
    • (surgery)
      • operative intervention,
        • minor surgery discussed:
        • major surgery discussed:
      • procedures,
  • consideration for level of care:
    • escalted care, ie admitted patient
    • de-escalted care,
      • due to patient's poor prognosis and severity of illness patient/family elected for dnr, focus on comfort and treatable conditions without exposing patient to diagnostics/interventions not in their goals of care
      • polst in chart and reviewed,
        • dnr/dni,
        • comfort measures only,
        • selective treatments,
  • medications considered:
    • considered administration in the ed but deferred
    • added to patient's home regimen:
    • changed:
  • disposition considerations:
    • admission. considered admission, however patient is clinically well and would benefit from trial on outpatient basis.
  • observation note:
    • total observation time
    • start of observation time
    • end of observation time
    • decision for disposition made after observation. disposition to
    • observation performed in order to attempt to safely preclude an inpatient admission.
    • observation was performed given
      • diagnostic uncertainty (i.e. serial examinations and assessments by me to elucidate likelihoodof a pathologic process).
      • to determineintensity therapy required (i.e. there was a reasonable possibility that by observing the patient's response to therapy, an admission may be abated and safely discharged).
    • observation by me in ed.
    • the observation was utilized as the primary diagnostic tool during that time.
    • of note, additional history was obtained at this time and there was no family history contributoryto the patient's current condition.
    • given patient had initial complaint concerning for significant deterioration resulting in severe morbidity and potential mortality, patient required direct observation and monitoring in the emergency department with trending of vital signs, telemetric monitoring reviewed by me, frequent reassessments by nursing with communication with me of status, re-accessments in addition by me, which were all required for patient's safety during that time (monitoring while administering medications with risk for cns/cardiac/pulmonary adverse reactions) and to determine patient's disposition by assessing for response to interventions/treatment. patient was observed under my supervision.
    • revenue code: 0762. hcpcs code g0378
  • critical care procedure note:
    • authorized and performed by: attending physician
    • total critical time:
      • minutes.
        • cpt code
    • indication for critical care including pt has exhibited risk factors for and symptoms and signs concerning for impending deterioration included compromise of
      • airway,
      • respiratory stability,
      • cardiovascular collapse,
      • cns irreversible damage,
      • metabolic derangements
      • renal failure
      • fulminant hepatic failure
    • primary diagnosis:
      • ((primary diagnosis must be one of these for critical care time to be documented))
    • due to patient having a presentation that is concerning for a potentially pathologic process causing an resulting in significant morbidity and potential mortality, the patient required emergent evaluation in the emergency department including emergent diagnostics, emergent assessment and evaluation, and emergent and directed treatment in order to mitigate risk for life-threatening deterioration. the critical care time as indicated above included discussing history with patient, examining patient, interpreting vital signs including pulse oximetry, initiating and interpreting diagnostics, and clinical acumen in order to synthesize patient's presentation to develop treatment plan and emergently implement the requisite steps. this part of my care the patient is exclusive of other billable procedures, specifically procedures, treating other patients, and any educational time. please refer to the above rationale for further documentation regarding the critical nature of the patient during my care.
    • this critical care time is separate from teaching or other separately billable procedures or treating other patients.
  • counseling:
    • patient/family educated to the extent possible in terminology matched to their understanding on diagnostics, assessment, and treatment plan along with the risks inherent to the diagnostics and therapeuticsand plan. patient/family amendable and in agreement with above plan. all questions and concerns addressed and answered.
    • attempted shared decision making in discussion with patient/family in all circumstances where feasible and possible.
    • attempted to explain and obtain patient's approval for plan however unable to do so secondary to patient's condition and the requirement of emergent evaluation and interventions.
  • supervision:
    • discussed and obtained approval/confirmation of evaluation (history, exam, diagnostics) and plan (assessment, interventions, disposition) with ed attending physician
  • of note, follow up over-read mechanism in place for over-reads and follow up of pending diagnostics.

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