Clinical Archives - PA Trauma

We have a patient with pneumocephalus but no skull fracture. We believe the pneumocephalus is due to his Lefort 2 fracture. Is sequential neurologic documentation required for this patient?

First, I want to remind you that the sequential neurological documentation data element is optional and is no longer submitted to the central site. Centers now have the liberty to abstract this data element as they see fit for their institution, or not at all. In other words, this data element is a facility-specific data …

Continue reading “We have a patient with pneumocephalus but no skull fracture. We believe the pneumocephalus is due to his Lefort 2 fracture. Is sequential neurologic documentation required for this patient?”

We have a patient where the nurse has documented in her notes that etomidate and rocuronium was given prior to intubation. She has documented the time, dose and med but only in her notes. I do not see this on the MAR or the electronic flowsheet. Can I still use this that this was given?

If you are confident this information documented in the nursing notes is accurate, you can use it. I find it unusual it is not also documented elsewhere. I recommend you use caution and perhaps query the providers to ensure these medications were given to the patient.

In the event that documentation supports that the patient does have a documented rate of zero, and an assisted rate of 18 we can or cannot use the documentation of ZERO for unassisted because of the following in the PTOS book: “Do not enter ‘0’ if controlled rate is entered.”?

You cannot record both a controlled and an uncontrolled rate in PTOS. The idea is that you are capturing the initial vitals. For respiratory rate, you are capturing the initial respiratory rate, which will be either controlled or uncontrolled.

I am receiving a check for the Sequential Neurological and Hourly Vital Sign elements. I thought these were optional? Why is there a check to complete if they are optional?

You are correct that these are optional elements that are NOT required to be completed. PTSF will work with ESO to modify or remove this check.

How are centers (or how can we) handle when a patients height and weight are documented on the EPIC timeline of one of our own network hospitals? A referring facility within our network documented on the same timeline for this patient transferred to our facility. Unfortunately these were not re-documented during the encounter for treatment of this patients traumatic injury. Just wondering if we are able to use or not?

You are not to use data from the referring facility here. You must record the first height and weight documented within 24 hours of ED or hospital arrival at your facility.