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?”
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.
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.
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.
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.