Documentation

  • [2] [b]Supplemental Documentation:[/b]
    • [1] [01] [b]OBSERVATION NOTE:[/b]
      • Total observation time __
      • Start of observation time __
      • End of observation time __
      • Decision for disposition made after observation. Disposition to __
      • [01] Observation performed in order to attempt to safely preclude an inpatient admission.
      • [01]  [1] Observation was performed given
        • diagnostic uncertainty (i.e. serial examinations and assessments by me to elucidate likelihood of a pathologic process).  
        • to determine intensity 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). 
      • [01] [1] Observation by me in ED.
      • [01] [1] The observation was utilized as the primary diagnostic tool during that time.
      • [01] [1] Of note, additional history was obtained at this time and there was no family history contributory to the patient’s current condition. 
      • [01] [1] 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.
      • [01] [1] Revenue code: 0762.  HCPCS Code G0378
    • [1] [01] [b]CRITICAL CARE PROCEDURE NOTE:[/b]
      • [01] Authorized and performed by: Attending physician __
      • [01] [1] Total critical time:
        • [01] [__,31,32,33,34,35,36,37,38,39,40;billingcctime] minutes.
          • [01] [1] CPT Code [billing_cctime|if billingcctime less-than 74:99291] [billing_cctime|if billingcctime greater-than 74:99292
      • [01] [1] 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
        • __
      • [01][1] PRIMARY DIAGNOSIS:
        • ((primary diagnosis must be one of these for critical care time to be documented))
        • [01] [Acidosis with aggressive management,Acute Coronary Syndrome (ACS-possible MI) with progressive pain management,Active bleed with admit to OR,Anaphylactic shock,Angina – unstable – aggressive management,Atrial fibrillation with tachycardia not responding immediately to treatment,Asthma -aggressive treatments-frequent monitoring,Comatose/unconscious-unknown cause at presentation,COPD/CHF severe exacerbation,Dehydration with significant metabolic/ chemistry changes,Head injury-severe-unresponsive,Hyperkalemia with insulin/bicarb treatment,Hypernatremia with mental status change,Overdose-aggressive treatment-lavage or acute vital sign changes,Pneumothorax with at least mild/moderate respiratory distress,Pulmonary edema or emboli,Rapid heart rate requiring IV therapies and/or close monitoring in ED,Seizure, new onset or with disorder hx-postictal with intensive drug management,Sepsis/septicemia with hypotensive management,Severe bleeding requiring transfusion,Shock-unresponsive patient,Status Asthmaticus – patient’s inability to respond during an asthma attack,Status Epilepticus,Stroke, acute, with paralysis not just parasthesia,Subdural-subarachnoid-bleding into the brain,Suicidal ideation-clear & immediate threat-requiring chemical/physical restraints,Trauma-altered consciousness-life or limb threatened,Unstable vital signs;var_billingccdx]
      • [01] [1] 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.
      • [01] [1] This critical care time is separate from teaching or other separately billable procedures or treating other patients.
    • [01] [1] COUNSELING:
      • [01] 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 therapeutics and plan. Patient/family amendable and in agreement with above plan. All questions and concerns addressed and answered.
      • [01] Attempted shared decision making in discussion with patient/family in all circumstances where feasible and possible.
      • [1] 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.
    • [1] SUPERVISION:
      • Discussed with attending.  Obtained approval/confirmation of evaluation (history, exam, diagnostics) and plan (assessment, interventions, disposition) with ED attending physician __
      •  Evaluated patient with resident physician. I have evaluated the patient and discussed the patient’s history, exam, diagnostics, and plan with the resident physician and agree with plan as stated by resident physician.
    • [1] [1] Of note, follow up over-read mechanism in place for over-reads and follow up of pending diagnostics.

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