Clinical Archives - PA Trauma

We have a patient who is legally blind and has two fake eyes. We have documentation in the chart stating spontaneous eye movement and a total GCS of 15 within the first 30 mins of arrival. How should we answer the question for GCS eye? If the patient were to have a head injury, what would we answer for pupillary response?

Great questions! For GCS-Eye Opening, the assessment is of the stimulus to induce eye opening, not the vision itself. As stated, you have documentation of GCS 15 and that would …

Continue reading “We have a patient who is legally blind and has two fake eyes. We have documentation in the chart stating spontaneous eye movement and a total GCS of 15 within the first 30 mins of arrival. How should we answer the question for GCS eye? If the patient were to have a head injury, what would we answer for pupillary response?”

Does the initial hospital oxygen saturation lever and the supplemental oxygen have to be noted together to be captured or can they be captured separately?

Supplemental oxygen is determination of the presence of supplemental oxygen during assessment of initial ED/hospital oxygen saturation level, so it is asking if they had supplemental at the time of …

Continue reading “Does the initial hospital oxygen saturation lever and the supplemental oxygen have to be noted together to be captured or can they be captured separately? “

Can you clarify how the data element, Intervention Offered should be answered? It’s a little unclear in the manual at the bottom of page 114. It only states: Yes, No or Unknown? And the data element in collector has an “Inappropriate” option. Example: SBIRT and Screen Result were negative. Should Intervention offered be “Inappropriate” or “NO”?

Thanks for the question, that was changed after initial release. If the patient was screened, then you will answer this question whether screening was positive or negative. Answer Yes, No, …

Continue reading “Can you clarify how the data element, Intervention Offered should be answered? It’s a little unclear in the manual at the bottom of page 114. It only states: Yes, No or Unknown? And the data element in collector has an “Inappropriate” option. Example: SBIRT and Screen Result were negative. Should Intervention offered be “Inappropriate” or “NO”?”

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 …

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 …

Continue reading “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?”

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 …

Continue reading “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.”?”

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 …

Continue reading “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?”