trauma room

No, if Trauma is not called in ED, you would enter NO for “was alert called”, and just enter trauma consult call/arrive on the consults side. This is similar to direct admit scenarios.

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.

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 …

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.

That is for all studies, yes.

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 …

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.     

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

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 …

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 …