In these situations, Height of Fall is recorded with an I for inappropriate. You can record any additional information you wish (excluding patient/provider specific information (PHI)) in the Cause of Injury Specify field.
Pre-existing conditions – E.00 Mental/Personality Disorder. Looking at this definition it says to refer to the NTDB definition that is consistent with APA DSM 5, 2013 – looking at this, it still isn’t really clear what to include. The following two are the ones we struggle with all the time. -Major Depressive disorder – if a doctor writes depression, is that sufficient? -Social Anxiety Disorder – if written as anxiety, is that enough?
This definition is very specific. Both the NTDS definition and PTOS definitions are consistent with the American Psychological Association (APA) DSM 5, 2013, and documentation of “depression” is not the same as the diagnosis of a major depressive disorder. The patient must have a diagnosis of a major depressive disorder OR received treatment for major …
Any previous head injury that caused anything from drowsiness to severe injury. When we say “A TBI must be clearly documented” this means any brain injury, so SDH qualifies. You do not need the actual text of “TBI”. You would often only see that wording if they don’t get a diagnosis.
Would a patient that has a refusal for blood products due to religious reasons prior to arrival and then noted on their chart stating the same be considered Advanced Directive Limited Care “written request limiting life-sustaining therapy”?
The current definition for Advanced Directive Limited Care states “the patient had a written request limiting life-sustaining therapy, or similar advanced directive, present prior to arrival at your center.” If the refusal for blood products due to religious reasons was documented in the patient’s chart prior to arrival at your center, I recommend capturing this …
We are looking for clarification regarding what is considered abuse. I understand, for example, a parent assaulting a child, a spouse/significant other assaulting a spouse, an adult child assaulting an elderly parent is abuse,, but is any physical assault considered abuse for the first registry question “was patient being evaluated for abuse?” or are there specific criteria that constitutes abuse? For example, an acquaintance or neighbor as a one-time event assaulting the patient, how would we answer that first registry question? Or a guy is sitting at a bar and someone comes up and hits him?
Please refer to the Best Practices Guidelines for abuse. If you cannot locate this resource, please contact PTSF staff, and we can provide it for you. I hope this document helps clarify abuse for you. This resource provides great information, and best practices for abstraction as well. Any physical assault is not abuse. However, according …
In situations where patients fall in place while going up steps, we recommend recording a fall height of 0 = fall on same level. This is only true if their fall did not result in a fall down the stairs. For mechanism in ICD-10, you will use the category for fall from/on stairs.
Mechanism of injury plays no role in the Pre-hospital Cardiac Arrest definition. This pre-existing condition should be considered for every PTOS patient regardless of their MOI or diagnoses.
To clarify, the inclusion of CHF, if there is a diagnosis of CHF in the chart but there is no documentation of symptom onset or increasing onset within 30 days of admission (the patient is “stable” in regard to their CHF), PTSF does not want CHF included as a PEC?
That is correct. There must be documentation of the condition itself AND documentation of onset or increasing symptoms within 30 days prior to injury in order to include A.03-CHF as a PEC.
Please provide direction on whether the Advanced Directive Limited Care condition should be included based on the following document that is scanned into our medical record labeled as Living Will with the following excerpts. TO MY FAMILY, MY PHYSICIAN, MY LAWYER, MY MINISTER, TO ANY MEDICAL FACILITY IN WHOSE CARE I HAPPEN TO BE, TO ANY INDIVIDUAL WHO MAY BECOME RESPONSIBLE FOR MY HEALTH, WELFARE OR AFFAIRS:If the time comes when I, patient X, can no longer take part in decisions for my own future, let this statement stand as an expression of my wishes, while I am still of sound mind. If the situation should arise in which there is no reasonable expectation of my recovery from physician or mental disability, I request that I be allowed to die and not be kept alive by artificial means or “heroic measures.” I, therefore, ask that medication be mercifully administered to me to alleviate suffering even though this may hasten the moment of death.
Yes, your example would meet Advanced Directive assuming it was either on the patient’s person on arrival, or already on file with your hospital. It must be a written request (not verbal), limiting life-sustaining therapy, and present on arrival or prior. The NTDB has listed Living Will has one example of an Advanced Directive; other …
In order to capture this as a pre-existing, the patient’s advanced directive to limit life-sustaining treatment must have been present on their person on arrival or already on file at your center.