Pediatric Fever – © MedTx, LLC 2017

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  •   CC:  with pertinent PMH/PSH presents with
  •   Initial assessment of stability of patient:
    • Pediatric Assessment Triangle:
      • Toxic Appearing.
        • Emergent interventions/diagnostics precluded full H&P at this time.
      • Non-toxic Appearing,
        • normal
          • appearance,
          • work of breathing,
          • circulation to skin,
    • AVPU
  •   HPI (complaint focused history):
      • General Pediatric Information:
        • Comorbidities
        • Vaccine UTD
          • to vaccines
        • Birth/family history:
          • No significant complications of birth history.
          • No significant contribuatory family history
        • Any findings suggestive of neglect or non-accidental trauma
      • History suggestive of patient’s level of sickness:
        • Lethargy/AMS
        • well-hydrated based upon hx of PO intake/frequency of urinary output
      • Complaint Specifics of history
        • Temperature
          • Highest recorded temperate ,
          • Method recorded ,
          • Anti-Pyretics being administered at home
          • Time of last anti-pyretic prior to arrival ED
          • Duration of persistence of fever ,
          • Onset of illness ,
          • uncontrollable shaking consistent with rigors
      • Localizing symptoms (to the extent is possible to ascertain by child/care giver):
        • Ear pain suspected by parents.
        • Sore throat suspected by parents.
        • Injected sclera per parents.
        • Rhinorrhea.
        • cough.
        • Nb/nb vomiting.
        • Nb/non-melanotic/normal color diarrhea.
        • Indications of abdominal pain.
        • Poor PO tolerance.
        • Rash
          • Location of rash: ,
        • Joint pain.
        • Indications suggestive of muscle pain.
        • No suspect source elucidated by interview with care giver.
    •  
  •  REVIEW OF SYSTEMS (Pediatric):
    •   Constitutional:
      • ,
      • in distress
      • fevers,
      • rigors,
      • as noted in HPI
      • ,
    •   ENT:
      • rhinorrhea,
      • otalgia
        • given pulling at ears,
      • sore throat,
      • as noted in HPI
      • ,
    •   Eyes:
      • injected sclera
      • as noted in HPI
      • ,
    •   Cardiac:
      • murmur on cardiac auscultation.
      •   chest pain,
      • as noted in HPI,
      • ,
    •   Pulmonary:
      • shortness of breath,
      • cyanosis,
      • cough,
      • as noted in HPI
      • ,
    •   GI:
      • abdominal pain suspected by parents,
      • vomiting,
      •   BRBPR, dark tarry stool,
      • diarrhea
      • as noted in HPI,
      • ,
    •   GU:
      • GU / peri rectal rash,
      • dysuria,
      • as noted in HPI
      • ,
    •   Nuero:
      • lethary,
      • nuccal regidity,
      • as noted in HPI,
      • ,
    • MSK:
      • no recent trauma
      • no indications of joint pain, limitations in mobility, swollen joints.
      • no focal asymmetry in weakness noted
      • as noted in HPI
      • ,
    •   Skin:
      • no rashes, specifically also no petechiae
      • as noted in HPI
    •   ID:
      • no recent antibiotics,
      • as noted in HPI
      • ,
  •   PMH/PSH/PSFH:
    •   PMH/PSH:
      • medical/surgical history pertinent to chief complaint as noted in HPI
    •   SH:
      • domiciled,
      • family,
      • ,
    • FH:
      • review and non-contributory to patient’s presenting complaint.
      • ,
  •  EXAM:
    •   VITALS: (overall impression of vital signs with repeat vitals in EMR as RNs re-accesses patient):
      • HR:
          • repeated after patient not agitated and HR normalized
        • ,
      • BP:
        • normotensive.
        • hypertensive
          • repeated after pt not agitated and BP normalized
        • hypotensive.
      • O2 sat:
        • hypoxia on my interpretation of oximtery
        • peri baseline O2 sat
      • RR:
          • repeated after pt not agitated and normalization of RR
    •   PHYSICAL EXAM:
      •   Constitutional:
        • well-nourished,
        • distress,
      •   HEENT:
        •   Head: atraumatic head,
        •   Eye:
          • peri-orbital erythema nor swelling,
        •   EOM grossly intact,
        •   Nose: rhinorrhea,
        •   Ear exam:
          • mobile, non-erythematous TM with white reflex,
          • non-mobile, erythmeatous TM,
            • on left
            • on right
          • discharge from ears,
        •   Throat exam:
          • no erythema, no purulent exudate,
          • no deviated uvula,
          • mildly swollen tonsilles
          • mildly swollen cervical lymph nodes
          • erythema at base of throat,
          • purulent exudate,
          • cervical lymphadenopathy,
        • No torticollis,
        • No stridor,
      •   Cardiovascular:
        • no r/m/g,
      •   Pulmonary:
        • Lungs:
          • CBTA,
          • rhoncherous breath sounds
            • on left,
            • on right,
            • at base,
            • at superior aspect,
          • wheezing
            • expiratory only
            • inspiratory and expiratory
            •  significant decreased aeration
            • focal at
            • throughout
          • rales,
            • on left,
            • on right,
            • at base,
            • at superior aspect,
        •   Respiratory effort:
          • No respiratory distress, non-labored breathing, no retractions,
          • respiratory distress,
            • mild,
            • moderate,
            • severe,
        • symmetric breath sounds
      •   GI:
        • abdomen soft,
        • abdomen non-tender in all 4 quadrants,
        • TTP
          • diffusely,
          • in RUQ,
          • in RLQ,
          • in LLQ,
          • in LUQ,
          • in epigastric region,
      •   Neuro:
        • Normal LOC.
        • Acting normal per parents.
        • No nuccal rigidity
        • No gross focal neurological deficits.
      •   MSK:
        • no deformities,
        • moving all extremities
      •   Skin:
        • No rashes.
      •  GU exam:
        • No rashes/abnormalities of skin in GU / peri rectal area.
        •  Male specific exam:
          • Testicular exam:
            • palpable testis without tenderness
            • normal testicular lie,
            • able to elicit cremaster reflexes,
        •  Female specific exam:
          • No suprapubic / RLQ / LLQ TTP
  •  ———————————————————————–
  •    ED COURSE and MDM:
  •   Working Impression/Empiric Management:
    • Evaluation for Pediatric Fever
  •  Diagnostically:
    •   Labs:
      •  Ordered, pending at this time.
        • Labs ordered:
        • CBC,
        • BMP,
        • LFTs/lipase,
        • UA,
        • Urine Cx
        • lactate
        • Blood Cx
          • x1
          • x2
        • Influenza, Biofire
        • CRP,
        • ESR,
      •  Reviewed and interpreted/correlated to clinical scenario to inform diagnosis and plan by me.
        •  CBC:
          • No significant unexpected anemia, No significant leukocytosis, No thrombocytopenia.
          • Hg
            • anemia,
          • wbc’s
            • luekocytosis
              • suspect demarginalization given lack of infectious findings on hx/exam,
              • suggestive of infectious process,
              • concerning for malignancy, advised to for follow up,
            • leukopenic
              • neutropenic
                • ((ANC < 500)),
          • platelets:
            • thrombocytopenic
              • ((platelets < 150k))
              • transfusion not indicated
                • given suspected consumptive process
                • ((ITP, TTP, HIT)),
            • transfusion indicated given
              • <10 k (regardless that pt is asymptomatic),
              • <20k and and planned CVP or pt febrile,
              • <50k and planned LP or neurosurgical procedure,
          • pancytopeniac
            • unclear etiology, will initiate eval w/ completion of eval and monitoring/treatment to be continued as outpatient after ED
        •  BMP:
          • No significant pathologic electrolyte derangements.
          • AKI,
            • ((50% increase from baseline))
            • BUN/Cr >20 suggestive of prerenal process,
              • will administer IVF
              • and recheck
          • Anion gap
            • ((> 12)),
            • will repeat after IVF,
          • acidotic suggested by low bicarb,
        •  LFTs/lipase:
          • No laboratory evidence of hepato-biliary pathology.
          • Transaminitis without elevated bilirubin, suggestive of hepatic pathology
          • Elevated direct bilirubin suggestive of biliary pathology
          • Elevated indirect bilirubin suggestive of increased rbc breakdown
        •  UA:
          • From catheterized specimen given patient not potty trained.
          • Not consistent with urinary tract infection.
          • Urine Cx sent with follow mechanism in place
          • Equivocal for infection
            • Empirically treated.
            • UCx sent with f/u mechanism in place
        •  Influenza
          • negative
        •  Biofire
          • negative
        •  Markers of inflammation
          • CRP (suggestive of more acute inflammation)
            • wnl
            • elevated
          • ESR :(suggestive of more chronic inflammation)
            • wnl
            • elevated
    •   Radiographically:
      •  Radiographs
        • ordered, pending at this time.
        • reviewed, interpreted by me.
        • reviewed by me, agree with radiology interpretation.
        • reviewed and interpretated by me.
        • (This is an ED prelim radiographic interpretation in order to increase chance of finding obvious emergent pathology which can be intervened upon and to minimize delay in care secondary to delay of radiology to be able to provide formal reads. Given these studies require board certified radiologists to review and formal reads are beyond the scope of Emergency Medicine, institutional protocol in place which will alert current care team/patient for over-reads/changes/critical reads).
      •  CXR:
        • Normal study: no tracheal deviation, non-widened mediastenum, normal cardiac boarder, no pleural effusion, no air under diaphragm, no focal consolidation, no diffuse opacification, no PTX, no gross bony abnormalities.
        • lobar opacity, consistent with lobar pneumonia
        • diffuse radio-opacities consistent with atypical pneumonia
      •  XR of joint / extremity of suspect:
      •  Advanced Imaging:
        • US abdomen
          • negative for appendicitis,
          • unable to visualize appendix,
          • negative for hepato-biliary pathology,
        • CT A/P
          • w/ contrast,
          • non-con,
          • negative for acute intra-abd pathology
  •  Therapeutically:
    •  Empirically:
      •  IVF
        • 20 cc/kg,
          • x1
          • x2
          • x3
      •  Anti-pyretics / Analgesics:
        • acetaminophen,
        • ibuprofen,
      •  Anti-emetics
        • ondansetron (zofran)
          • IV
          • ODT ((oral dissolving tablet))
  •   Assessment/Plan:
    • with PMH/PSH of presents with
    • Per caregiver, vaccines UTD for age of patient.  
      •   Evaluated for toxicity.
        •  Toxic appearing pediatric patient.
          • Given pt’s high risk for deterioration, morbidity, mortality, conservative approach of full septic work up and treatment pursued.
            • Diagnostically:
              • CBC, BCx x1, Lactate, UA (cathed) w/ micro, UCx, CXR, LP
              • stool studies
                • indicated given pt has diarrhea
                • not indicated given pt has not diarrhea
            • Therapeutically:
              • Abx:
                • amp 100 mg/kg / gen 5mg/kg
                • amp 100 mg/kg / cefotaxime 50-100 mg/kg
                • ceftriaxone 50-100mg/kg (risk of precipitating hyperbilirubinemia sufficiently low given pt is > 6 wks)
                • acyclovir 20 mg/kg
              • IVF: 20 cc/kg, repeat PRN evaluation of hydration status
            • Dipso: Admitted
        •  Non-toxic.
          • Utilized age, risk stratification criteria to inform diagnostics, therapeutics, and disposition:
            • 0- 90 days.
              • Philadelphia criteria employed.
                • Meets inclusion criteria:
                  • Age 29-60 days
                  • T >38.2 C
                  • Exam: well, non-focal
                  • Labs:
                    • wbc’s > 15k
                    • band/neutrophil ratio < 0.2
                    • UA < 10 wbc’s, neg gram stain
                    • CXR normal
                    • Stool neg (if obtained)
                    • LP performed, CSF <8 wbc’s, neg gram stain.
                • Meets all low risk criteria, will discharge without antibiotics.
                • High risk, IV abx and admit.
                  • Abx:
                    • amp 100 mg/kg / gen 5mg/kg
                    • amp 100 mg/kg / cefotaxime 50-100 mg/kg
                    • ceftriaxone 50-100mg/kg (risk of precipitating hyperbilirubinemia sufficiently low given pt > 6 wks)
                    • considered acyclovir 20 mg/kg,
                      • and administered.
                      • and deferred at this time.
                  • IVF 20cc/kg bolus
                    • repeated PRN evaluation of hydration status
                • ((Performance))
                  • Sensitivity 98%
                  • Specificity 42 %
                  • PPV 14%
                  • NPV 99.7%
              • Rochester criteria employed:
                • Meets inclusion criteria:
                  • Age < 60 days
                  • T > 38.0 C
                  • Exam: well, non-focal
                  • Labs:
                    • wbc’s 5k-15k, Abs bands <1.5k
                    • UA <10 wbc’s
                    • Stool < 5wbc’s
                  • Stool neg (if obtained)
                  • LP deferred.
                • Meets all low risk criteria, will discharge without antibiotics.
                • High risk, IV abx and admit.
                  • Abx:
                    • amp 100 mg/kg / gen 5mg/kg
                    • amp 100 mg/kg / cefotaxime 50-100 mg/kg
                    • ceftriaxone 50-100mg/kg (risk of precipitating hyperbilirubinemia sufficiently low given pt > 6 wks)
                    • considered acyclovir 20 mg/kg,
                      • and administered.
                      • and deferred at this time.
                  • IVF 20cc/kg bolus
                    • repeated PRN evaluation of hydration status
                • ((Performance))
                  • Sensitivity 92%
                  • Specificity 50 %
                  • PPV 12%
                  • NPV 98.9%
              • Boston criteria employed:
                • Meets inclusion criteria:
                  • Age 28-89 days
                  • T > 38.0 C
                  • Exam: well, non-focal
                  • Labs:
                    • wbc’s 20k
                    • UA <10 wbc’s
                    • LP performed, CSF <10 wbc’s
                    • CXR normal (if obtained)
                • Meets all low risk criteria, will discharge WITH empiric antibiotics.
                  • Abx:
                    • amp 100 mg/kg / gen 5mg/kg
                    • amp 100 mg/kg / cefotaxime 50-100 mg/kg
                    • ceftriaxone 50-100mg/kg (risk of precipitating hyperbilirubinemia sufficiently low given pt > 6 wks)
                    • considered acyclovir 20 mg/kg,
                      • and administered.
                      • and deferred at this time.
                  • IVF 20cc/kg bolus
                    • repeated PRN evaluation of hydration status
                • High risk, IV abx and admit.
                  • Abx:
                    • amp 100 mg/kg / gen 5mg/kg
                    • amp 100 mg/kg / cefotaxime 50-100 mg/kg
                    • ceftriaxone 50-100mg/kg (risk of precipitating hyperbilirubinemia sufficiently low given pt > 6 wks)
                    • considered acyclovir 20 mg/kg,
                      • and administered.
                      • and deferred at this time.
                  • IVF 20cc/kg bolus
                    • repeated PRN evaluation of hydration status
                • ((Performance))
                  • Sensitivity not available
                  • Specificity not available
                  • PPV not available
                  • NPV 94.6
              • Baraff synthesis of Rochester, Philadelphia, and Boston criteria:
                • Meets criteria:
                  • Age 29 – 90,
                  • previously healthy,
                  • uncomplicated nursery stay,
                  • non toxic clinically,
                  • no focal source
                  • low risk labs:
                    • wbc normal (5k-15k), < 1.5k bands
                    • normal wbc (neg gram stain and <5 wbc)
                    • neg CSF gram stain, cell counts < 8 wbc’s, if obtiained
                    • stool < 5 wbc’s if diarrhea
                • Two Options:
                  • Low risk: discharge home w/ f/u
                  • Low risk: LP, ceftriaxone 50mg/kg IV/IM, re-eval at 24 hrs
              • Febrile infant. (conservative approach, risk factors or no follow up)
                • Incomplete development of blood brain barrier, incomplete vaccination status.
                • While I appreciate literature that may lead to a more liberal approach, given pt’s high risk for deterioration, morbidity, mortality, conservative approach of full septic work up pursued.  Further treatment plan per discretion of inpatient team where there exists luxury of watching patient’s clinical trajectory.
              • Dipso: Admitted
            • Afebrile in ED with no hx of recent antipyretics.
              • Therefore suspect pt is truly afebrile. On thorough history and physical exam, no evidence of malignant process nor bacterial infection. Patient is well hydrated based upon history and exam. Therefore patient is appropriate for outpatient care, prompt follow up with primary care physician and discussed return precautions with parents.
            • Afebrile in ED with recent anti-pyretic use with observation showing no fever.
              • Given history of recent anti-pyretic, patient was observed in the emergency department  for duration of time where based upon time of administration of antipyretics and known duration of action of anti-pyresis, lack of fever on repeat vital signs not likely attributable to anti-pyretics.  Therefore patient is likely afebrile. On thorough history and physical exam, no evidence of malignant process nor bacterial infection. Patient is well hydrated based upon history and exam. Therefore patient is appropriate for outpatient care, prompt follow up with primary care physician and discussed return precautions with parents.
        • 3mo – 3 yr.
          • Afebrile in ED with no hx of recent antipyretics.
            • Therefore suspect pt is afebrile. On thorough history and physical exam, no evidence of malignant process nor bacterial infection. Patient is well hydrated based upon history and exam. Therefore patient is appropriate for outpatient care, prompt follow up with primary care physician and discussed return precautions with parents.
            • Treated any evidence of bacterial source.
          • T 38 – 39 in ED (febrile without hyperpyrexia).
            • Therefore suspect pt is febrile though not sufficiently high fever to warrant additional diagnostics given on thorough history and physical exam, no evidence of malignant process nor bacterial infection. Patient is well hydrated based upon history and exam. Therefore patient is appropriate for outpatient care, prompt follow up with primary care physician and discussed return precautions with parents.
            • Treated any evidence of bacterial source.
          • Temp < 39 in ED with recent anti-pyretic use.
            • Discussed possibility of antipyretics causing temp in ED to not be reflective of true Tmax and therefore possibility of hyper-pyrexia (T >39).  Offered observation until anti-pyretics would have worn off and then recheck temp and decision on further diagnostics based upon that data.  However, parents elected for discharge and to return if detected hyper-paresis at home.  This approach is not unreasonable given on thorough history and physical exam, no evidence of malignant process nor bacterial infection. Patient is well hydrated based upon history and exam. Therefore patient is appropriate for outpatient care, prompt follow up with primary care physician and imported return precautions with parents.
            • Treated any evidence of bacterial source.
          • T > 39 (hyperpyrexia) in 90d – 3 mo.
            • With clear suspect source. Treated any evidence of bacterial source. Diagnostics for alternative sources not sufficiently likely to warrant further information at this time.
            • Fever of unclear source. Will risk stratify and guide diagnostics for possible UTI based upon pre-test probabilities:
              • Female. given < 3 yr, UA w/ mciro/UCx performed.
              • Male, uncircumcised, only if < 12 mo. UA w/ micro /UCx performed.
              • Male, circumcised, only if < 6 mo. UA w/ mirco/UCx performed.
              • No UA indicated given gender, age, circumcision status.
        • > 3 y/o.
          • Treated any evidence of bacterial source.
          • No evidence of bacterial source on hx/exam. Suspect fever of benign etiology, likely viral source. On thorough history and physical exam, no evidence of malignant process nor bacterial infection. Patient is well hydrated based upon history and exam. Therefore patient is appropriate for outpatient care, prompt follow up with primary care physician and discussed return precautions with parents.
        • Persistent fever if patient for > 5  days in non-toxic, vaccinated patient.
          • Given fever without remittence for >= 5 days, pt evaluated for Kawasaki disease:
            • Assess for classic Kawasaki Disease Criteria:
              • ((BURN and CRASH mnemonic  BURN >= 5 days of fever AND 4 out of 5:))
                • C – conjunctivitis (usually bulbar, bilateral, non-purulent)
                • R – rash (just about anything except vesicles, bullae)
                • A – adenopathy (usually cervical, singular, >1.5cm)
                • S – strawberry tongue (or other changes like lip redness, cracking)
                • H – hand and feet swelling/erythema, (peeling later in course)
            • Meets sufficient criteria fever > 5d AND 4/5 Kawasaki criteria,
              • Admitted for IVIG and echo
            • Meets sufficient criteria for incomplete but not not full Kawasaki Disease:
              • >5d fever and 2-3 criteria
              • ((OR))
              • age < 6 mo and fever >= 7d regardless of Kawasaki classic criteria
                • CRP, ESR, CBC, albumin, ALT, UA w/ micro
              • Dipso and treatment contingent upon results of laboratory analysis.
  •    Dx includes but in not limited to (pt does not meet reasonable likelihood/consistency with the dx to warrant additional pursuit of these entities (risks outweigh benefits of non-indicating testing)
    • bacteremia, sepsis, OM, PNA, strept pharyngitis, meningitis, HSV, myocarditis, intra-abd pathology, cellulitis, GU pathology, UTI, Kawasaki disease, URI, influenza, RSV.
      •    
    •  Plan:
      •  
  •   Re-evaluation:
    • Improved on re-evaluation.
      • On thorough re-evaluation, after patient was observed on telemetric monitoring, patient remains hemodynamically stable, normal vital signs, with normal level of alertness, repeat cardio-pulmonary-abdominal exam benign, and parents are amenable to discharge after observation period in the ED.
        • Abdominal Benign. Repeat abdominal exam  did not reveal any tenderness in any of the four quadrants. No rebound their guarding. patient  tolerated PO fluids and food to the emergency department without any recurrence of abdominal pain or vomiting.
        • Respiratory status
          • No signs of respiratory distress on exam, able to speak in full sentences without dyspnea. Respiratory related vital signs reassuring and suggestive of improvement. Improved respiratory exam compared to prior.
          • Unchanged respiratory status compared to prior.
          • Worsening respiratory status compared to prior.
      •     Diposition:
    • home.
      • Counseled patient’s care giver on assessment, impression, plan.
        • Discussed disposition options with patient after counseling as above and included option for continued observation in medical setting however shared decision making yielded joint decision for disposition to home with self and family observation, prompt follow up with PCP, and return to ED precautions.  Counseled on complaint specific return precautions given that there are pathologies that, while sufficiently unlikely to warrant further investigation at this time, may develop/worsen after discharge.  Counseled that early in a disease progress, a work up can be falsely non-revealing of more significant pathology however this does not exclude the possibility of developing serious pathology thereby underscoring the importance of prompt follow-up with PMD and low threshold for return to ED as needed.
    • Observation
      • Indication:
    • Admitted,
      • transfer of care kindly assumed by admitting team
      • at
      • level of care,
      • with service.
    • Sign out at change of shift, transition of care kindly assumed by oncoming ED team
      • to
      • pending
      • at
  •    Additional documentation:
    •    DIAGNOSIS:
      • ((Of note, to bill for critical care time, the primary diagnosis must be one of the diagnoses below))
      • ICD-10 code:
    •   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 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).
      •   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 contributory to 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.
      •   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 therapeutics and 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.