Acute Care Archives

If a total GCS is documented within 30 minutes of patient arrival, but the individual components of the score are not documented, can the total GCS be recorded in Collector?

Yes, if an incomplete GCS is documented, record as many of the GCS items as are available. This includes the Total GCS. You may record individual scores with a GCS of 3 [1,1,1] or 15 [4,5,6] recorded in the medical record.

Patient comes in with a known GI bleed (so this will not be a HE). He goes for a scope to see where his bleed is and ends up getting the bleed cauterized and he also receives blood products because of this blood loss. Would you suggest picking up the scope, cauterization and admin of blood products considering none of this was done to treat or diagnosis an injury? I know the procedures (other than blood) are not required to be picked up based on the guideline book even if it were for the injury but we pick up all procedures used to treat/diagnosis injuries. Just looking for some input to see what you’d think especially with the blood products.

You are correct that you do not need to capture procedures for coexisting medical conditions. Only procedures related to evaluation and treatment of injury are required to be included in PTOS. However, if the blood products were given within first 4 hours after ED/hospital arrival, you do need to capture those volumes appropriately under the …

Continue reading “Patient comes in with a known GI bleed (so this will not be a HE). He goes for a scope to see where his bleed is and ends up getting the bleed cauterized and he also receives blood products because of this blood loss. Would you suggest picking up the scope, cauterization and admin of blood products considering none of this was done to treat or diagnosis an injury? I know the procedures (other than blood) are not required to be picked up based on the guideline book even if it were for the injury but we pick up all procedures used to treat/diagnosis injuries. Just looking for some input to see what you’d think especially with the blood products.”

If you have a patient whose initial VS are documented at 14:59 and that included the oxygen saturation level but at that time the supplemental oxygen was not documented and then at 15:00 you had another set of VS documented and this time it did include the supplemental oxygen as room air noted, what would you suggest. Would you take unknown for the supplemental oxygen since it was not marked with the original O2 sat or would you take room air since this was documented within 30 minutes of arrival?

I recommend recording unknown as the determination of supplemental oxygen should be made during the assessment of the initial ED/hospital oxygen saturation level. In this situation the initial O2 sat is documented at 14:59 with no documentation of supplemental oxygen.

On page 95 of the guidelines for was patient monitored during CT studies during the resuscitative phase are you to take all studies done within the resuscitation phase or just the initial study? Thanks for clarifying!

That is for all studies, yes.

If a patient is seen by Internal Medicine in the ED prior to going to the floor as an admit, should I be collecting this in Others Called to ED section under Acute Care tab?

The only time the Others Called to ED section is required to be used is when the record is determined by your center to be an emergent case. And even in these situations, only specific providers are required to be captured based on those that are required to respond to the patient within a certain …

Continue reading “If a patient is seen by Internal Medicine in the ED prior to going to the floor as an admit, should I be collecting this in Others Called to ED section under Acute Care tab?”

I have a case that I am closing and when I click on the check, it notes that “ ED LOS is greater than 3 days”. Did I do something incorrectly? I verified that the patient’s ED LOS is in fact longer than 3 days.

This check was generated as a 3-day ED LOS is unusual. As long as you verified your data entry, and it is correct, you can simply verify this check.

If our facility screens for both opioids and fentanyl specifically, do we capture a patient who tests positive for both only under opioids or also under other and manually type in fentanyl?

Fentanyl is recorded under opioids and should not be captured separately.

Question about radiology studies performed in resuscitative phase- (under acute care section)- If there is a portable chest x-ray done and also x-ray of foot (does not say portable) – can I still put “1” yes, for was patient monitored during radiology? Or do ALL of the plain films need to be monitored for a yes response? The book is not specific or should I assume it means all radiology studies done in the resuscitative phase?

If the patient has multiple x-rays performed, there needs to be documentation of portable for all or documentation of the presence of the RN or CRNA, patient vital signs, and/or care rendered must be present for all x-rays that are not performed portable. If this is not the case, you should report 2, no, for …

Continue reading “Question about radiology studies performed in resuscitative phase- (under acute care section)- If there is a portable chest x-ray done and also x-ray of foot (does not say portable) – can I still put “1” yes, for was patient monitored during radiology? Or do ALL of the plain films need to be monitored for a yes response? The book is not specific or should I assume it means all radiology studies done in the resuscitative phase?”

Patient was a TX out of our ER to XYZ Hospital, except the patient stated they wanted to stop home before going to XYZ Hospital. Do I count this as an ER discharge and not a TX-out?

If there is documentation and/or an order that the patient is a transfer out and is to report to a receiving facility, PTSF recommends this patient be captured as a transfer out. You may have other transfer out by private vehicle patients that do the same, stop somewhere, they just don’t tell you. It isn’t …

Continue reading “Patient was a TX out of our ER to XYZ Hospital, except the patient stated they wanted to stop home before going to XYZ Hospital. Do I count this as an ER discharge and not a TX-out?”

I have a patient that went from the ER to PACU to have a nerve block done and then to a med surg floor, what ED destination would I use? What should I use for procedure location?

There are no guidelines in the PTOS Manual that tell you not to use PACU as a post ed location, it just isn’t in the current menu as an option. I recommend recording 15, other, for Post ED Destination and specifying PACU in the Specify field that opens. For Procedure Location, you can record 13, …

Continue reading “I have a patient that went from the ER to PACU to have a nerve block done and then to a med surg floor, what ED destination would I use? What should I use for procedure location?”