Professional Documents
Culture Documents
ED Coding Test
ED Coding Test
Chief Complaint
Motor Vehicle Crash restrained driver with frontal passenger side impact; airbag
deployment; denies LOC c/o bilateral hip and left ankle pain;
otherwise c/o pain all over
ED Disposition
Discharge
Discharge to home/self care.
ED Provider Notes
8/21/2016 06:52
Expand All Collapse All
History
Chief Complaint
Patient presents with
• Motor Vehicle Crash
restrained driver with frontal passenger side impact; airbag deployment; denies LOC c/o bilateral hip and
left ankle pain; otherwise c/o pain all over
HPI
3A/ 3A 8:29 AM is a 40 y.o. female who presents to the Christus Trinity Mother France ED with Motor Vehicle
Crash
PCP
Pt reports she was restrained driver in an MVC today. She reports a frontal passenger side impact with another
vehicle. She reports positive airbag deployment. Pt complains of neck pain, chest pain, back pain, and R ankle
pain. Pt denies LOC or head injury. Pt denies numbness, weakness, dizziness, visual disturbance, or n/v. No
other complaints at this time.
Social History
Substance Use Topics
• Smoking status: Current Every Day Smoker
• Smokeless tobacco: None
• Alcohol Use: None
Review of Systems
Constitutional: Negative for fever and chills.
HENT: Negative for congestion, rhinorrhea and sore throat.
Eyes: Negative for pain and visual disturbance.
Respiratory: Negative for cough, chest tightness and shortness of breath.
Cardiovascular: Negative for chest pain and leg swelling.
Gastrointestinal: Negative for nausea, vomiting, abdominal pain and diarrhea.
Genitourinary: Negative for dysuria and hematuria.
Musculoskeletal: Positive for myalgias, back pain, arthralgias and neck pain.
Skin: Positive for wound. Negative for rash.
Neurological: Negative for weakness and numbness.
Psychiatric/Behavioral: Negative for confusion.
Physical Exam
BP 114/74 mmHg | Pulse 72 | Temp(Src) 97.7 °F (36.5 °C) | Resp 15 | Ht 1.727 m (5' 8") | Wt 72.576 kg (160
lb) | BMI 24.33 kg/m2 | SpO2 94% | LMP 08/01/2016
Physical Exam
Constitutional: She is oriented to person, place, and time. She appears well-developed and well-nourished. No
distress.
HENT:
Head: Normocephalic.
Right Ear: External ear normal.
Left Ear: External ear normal.
Nose: Nose normal.
Eyes: Conjunctivae and EOM are normal. Right eye exhibits no discharge. Left eye exhibits no discharge.
Neck: Normal range of motion. Neck supple.
Cardiovascular: Normal rate, regular rhythm and normal heart sounds.
No murmur heard.
Pulmonary/Chest: Effort normal and breath sounds normal. No respiratory distress. She has no rales.
Abdominal: Soft. Bowel sounds are normal. There is no tenderness. There is no rebound and no guarding.
Musculoskeletal: Normal range of motion. She exhibits no edema.
Right ankle: Tenderness.
Neurological: She is alert and oriented to person, place, and time. No cranial nerve deficit.
Skin: Skin is warm. Abrasion and laceration noted. No rash noted.
Slight abrasions from seatbelt mark across pelvis. Abrasion to R ankle with tenderness to lateral
aspect. 1 cm laceration to R hand proximal to thumb.
Psychiatric: She has a normal mood and affect. Her behavior is normal.
Nursing note and vitals reviewed.
ED Course
Laceration Repair
Date/Time: 8/20/2016 10:53 AM
Performed by:
Authorized by: Consent:
Consent obtained: Verbal
Consent given by: Patient
Risks discussed: Pain
Anesthesia (see MAR for exact dosages):
Anesthesia method: Local infiltration
Local anesthetic: Lidocaine 1% w/o epi
Laceration details:
Location: Hand
Hand location: R wrist
Length (cm): 2
Repair type:
Repair type: Simple
Pre-procedure details:
Preparation: Patient was prepped and draped in usual sterile fashion
Exploration:
Hemostasis achieved with: Direct pressure
Wound exploration: wound explored through full range of motion and entire depth of wound probed
and visualized
Contaminated: no
Treatment:
Area cleansed with: Betadine and saline
Amount of cleaning: Standard
Irrigation solution: Sterile saline
Irrigation method: Syringe
Visualized foreign bodies: no
Skin repair:
Repair method: Sutures
Suture size: 5-0
Suture material: Prolene
Suture technique: Simple interrupted
Number of sutures: 2
Post-procedure details:
Dressing: Open (no dressing)
Patient tolerance of procedure: Tolerated well, no immediate complications
MDM
all labs reviewed
imaging results reviewed
ECG reviewed Sinus 70. Normal EKG.
EMS information reviewed
medical history reviewed
obtain history from someone other than the patient
Reviewed: History, labs, CT, xray and ECG.
Abdomen/pelvis:
No acute injury.
Re-Evaluations
9:40 AM
Discussed with patient results of this encounter and plan of care. Pt understands and agrees.
PRESCRIPTIONS:
New Prescriptions
CYCLOBENZAPRINE (FLEXERIL) 10 MG TABLET Take 0.5 tablets (5 mg total) by mouth 3 (three)
times daily as needed for Muscle spasms
HYDROCODONE-ACETAMINOPHEN (NORCO) 10- Take 1 tablet by mouth every 4 (four) hours as
325 MG TABLET needed for Pain
NAPROXEN (NAPROSYN) 500 MG TABLET Take 1 tablet (500 mg total) by mouth 2 (two) times
daily with meals
CTRL # 142670329346
I, MD, personally performed the services described in this documentation, ascribed in my presence,
and it is both accurate and complete.
ED Dispo
Discharge
ED Notes
8/20/2016 07:58
Expand All Collapse All
Bed: 3A
Expected date: 8/20/16
Expected time: 7:47 AM
Means of arrival: EMS - Champion
Comments:
Medic 20
40 female with MVC head-on at 65MPH driver, multiple pain
85, 111/75, 16, 98%
15/12, 14 IV, 75mcg fentanyl
8/20/2016 09:20
Expand All Collapse All
RN 8/20/2016 10:03
Expand All Collapse All
Patient transported to CT
RN 8/20/2016 10:05
Expand All Collapse All
Chief Complaint
Respiratory Distress sent to ER for unresponsive and difficulty breathing today from nsg
home
ED Disposition
Admit
ED Provider Notes
8/26/2016 20:19
Expand All Collapse All
History
Chief Complaint
Patient presents with
• Respiratory Distress
sent to ER for unresponsive and difficulty breathing today from nsg home
HPI TR1/ TR1 12:21 PM 65 y.o. male who presents to the ED with Respiratory Distress
Pt has known end stage COPD, lives at a NH. Pt was supposed to be evaluated for hospice today. He is
CURRENTLY a full code. Pt was on bipap at NH in Lindale and his sats dropped down to 60% when EMS
arrived to get him but o2 sats at 100% on now. Code 22 was called. Daughter called later, confirmed the full
code status. Pt on coumadin. Difficult to perform ROS due to pt's acute condition.
Family History
Problem Relation Age of Onset
• Hypertension Brother
Social History
Substance Use Topics
• Smoking status: Former Smoker
• Smokeless tobacco: Never Used
• Alcohol Use: No
Comment: HX ALCOHOLIC NEUROPATHY
Review of Systems
Unable to perform ROS: Acuity of condition
Physical Exam
BP 89/74 mmHg | Pulse 95 | Temp(Src) 97.2 °F (36.2 °C) | Resp 16 | Wt 50 kg (110 lb 3.7 oz) | SpO2 97%
Physical Exam
Constitutional: He appears well-developed. He appears cachectic. No distress. Face mask in place.
HENT:
Head: Normocephalic and atraumatic.
Right Ear: External ear normal.
Left Ear: External ear normal.
Nose: Nose normal.
Mouth/Throat: Mucous membranes are dry.
Eyes: Conjunctivae and EOM are normal. Right eye exhibits no discharge. Left eye exhibits no discharge.
Pupils dilated.
Neck: Normal range of motion. Neck supple.
Cardiovascular: Regular rhythm and normal heart sounds. Tachycardia present.
No murmur heard.
Pulmonary/Chest: No respiratory distress. He has no rales.
Poor airway movement
Abdominal: Soft. Bowel sounds are normal. There is no tenderness. There is no rebound and no guarding.
Musculoskeletal: Normal range of motion. He exhibits no edema.
Neurological: No cranial nerve deficit.
Skin: Skin is warm. No rash noted.
Psychiatric: He has a normal mood and affect. His behavior is normal.
Nursing note and vitals reviewed.
NON responsive during my exam. Did not flinch during either intubation or central line.
ED Course
Intubation
Date/Time: 8/26/2016 12:32 PM
Performed by:
Authorized by: Consent: The procedure was performed in an emergent situation.
Indications: respiratory distress and respiratory failure
Intubation method: lighted stylet
Patient status: awake
Preoxygenation: BVM
Laryngoscope size: Mac 4
Tube size: 7.5 mm
Tube type: cuffed
Number of attempts: 1
Post-procedure assessment: ETCO2 monitor, chest rise and CO2 detector
Breath sounds: equal
Cuff inflated: yes
ETT to lip: 25 cm
Tube secured with: ETT holder and adhesive tape
Chest x-ray interpreted by radiologist.
Chest x-ray findings: endotracheal tube in appropriate position
Patient tolerance: Patient tolerated the procedure well with no immediate complications
Comments: No resistance to intubation without sedation. No wheezing.
12:41 PM Pt began gagging, administered propofol 50 mcg/kg. BP=83/45, HR138, o2 sats at 94%.
MDM
all labs reviewed
imaging results reviewed
ECG reviewed
EMS information reviewed
medical history reviewed
obtain history from someone other than the patient
High risk problem: shortness of breath
Considered for SOB: Asthma, pneumonia, pneumothorax, COPD, tumor, congestive heart failure, coronary
artery disease, PE and pleural effusion.
Risk for respiratory failure: High risk.
Reviewed: Labs, ECG, xray and history.
Case discussed with critical care.
Critical care time: 75-105 minutes (90).
MEDS GIVEN IN ECC:
All Medication Orders
Start Ordered Status Ordering Provider
08/26/16 08/26/16 sodium chloride 0.9% bolus 2,000 Last MAR action:
1320 1315 mL Once New Bag/Started
Route: Intravenous Ordered Dose:
2,000 mL
REVIEWED:
12:47 PM EKG as reviewed by ECC Physician reports sinus tachy at 114. LBBB. Large P wave indicating
pulmonary disease.
CONSULTS:
1:43 PM Paged ICU.
1:43 PM Consult with Dr. - says she will come down and see the pt.
RE-EVALUATIONS:
1:30 PM HR=98, o2 sats at 100%, BP=71/59
1:31 PM Spoke with sister informed her of pt's condition. She understands that pt is at the end of his life. She
is waiting for the rest of the family to come and see him before he passes.
Discussed with family results of this encounter and plan of care. Family understands and agrees.
I, , MD, personally performed the services described in this documentation, ascribed in my presence,
and it is both accurate and complete.
ED Dispo
Admit
will be admitted to Dr - ICU.
ED Notes
8/26/2016 12:19
Expand All Collapse All
Bed: TR1
Expected date: 8/26/16
Expected time: 12:17 PM
Means of arrival: EMS - Champion
Comments:
Medic 20 65 male with copd sat was 60% but now 100% on bipap and 125 solumedrol. 109/70,
106
Events
Date/Time Event Pt Class Unit Room/Bed Service
08/26/16 1219 ED Arrival MFH EMERGENCY
CARE CENTER
08/26/16 1219 ED Roomed Emergency MFH EMERGENCY TR1/ TR1 Emergency
CARE CENTER
08/26/16 1347 Patient Update Inpatient MFH EMERGENCY TR1/ TR1 Emergency
CARE CENTER
08/26/16 1542 Admit from ED Inpatient MFH MEDICAL ICU 0122/01 General Medicine
08/26/16 1542 Admit from ED Inpatient MFH MEDICAL ICU 0122/01 General Medicine
09/03/16 1444 Discharge Inpatient MFH MEDICAL ICU 0122/01 General Medicine
Infusion Orders
sodium chloride 0.9% bolus 2,000 mL
Total time: 1 Hour 29 Minutes
Running start: 08/26/2016 1316 Running stop: 08/26/2016 1445
Associated diagnoses: Therapeutic class: Nutritional Products
CASE #2
Code the diagnosis codes appropriate for this visit:
Code the Professional CPTs for the ED visit
CASE #3
Diagnoses
Concussion, with loss of consciousness of
unspecified duration, initial encounter
Back pain, unspecified back pain laterality,
unspecified location
Chief Complaint
Fall Pt slipped and fell backward onto concrete. Pt complains of pain
all over but mainly head, neck, back pain. Pt is confused and
states she sees floaters in the air.
ED Disposition
Discharge
Discharge to home/self care.
ED Provider Notes
8/18/2016 08:50
Expand All Collapse All
History
Chief Complaint
Patient presents with
• Fall
Pt slipped and fell backward onto concrete. Pt complains of pain all over but mainly head, neck, back pain.
Pt is confused and states she sees floaters in the air.
HPI
PCP:
11:07 PM
57 y.o. female, presents to the Trinity Mother Frances Emergency Department with Fall.
Context: Pt reports to the ED with complaints of an accidental ground level fall onto concrete. Pt fell
backwards during the fall. Positive head trauma. Unknown LOC. Complains of back pain, head pain, neck
pain. Family states pt seems "confused". Daughter states the pt has hx of drug use. The patient/family
denies nausea, vomiting, diarrhea, chest pain, SOB.
Additional history: Hx of hip surgery and back surgery. Pt was evaluated in ED 2 days ago for dysuria.
Family History
Problem Relation Age of Onset
• Coronary artery disease
• Diabetes
• Stroke
• Cancer
grand mother had breast cancer
• Hyperlipidemia
• Diabetes Mother
• Hypertension Mother
• Diabetes Father
• Hypertension Father
Social History
Substance Use Topics
• Smoking status: Current Every Day Smoker -- 0.50 packs/day for 20
years
Types: Cigarettes
• Smokeless tobacco: Never Used
Comment: more than 30 yrs
• Alcohol Use: No
Review of Systems
Constitutional: Negative for fever and chills.
HENT: Negative for congestion, rhinorrhea and sore throat.
Eyes: Negative for pain and visual disturbance.
Respiratory: Negative for cough, chest tightness and shortness of breath.
Cardiovascular: Negative for chest pain and leg swelling.
Gastrointestinal: Negative for nausea, vomiting, abdominal pain and diarrhea.
Genitourinary: Negative for dysuria and hematuria.
Musculoskeletal: Positive for myalgias, back pain and neck pain. Negative for arthralgias.
Skin: Negative for rash.
Neurological: Negative for weakness and numbness.
Psychiatric/Behavioral: Positive for confusion.
Physical Exam
BP 206/110 mmHg | Pulse 71 | Resp 16 | Ht 1.575 m (5' 2") | Wt 113.399 kg (250 lb) | BMI 45.71 kg/m2 | SpO2
98%
Physical Exam
Constitutional: She is oriented to person, place, and time. She appears well-developed and well-nourished. No
distress. Cervical collar in place.
HENT:
Head: Normocephalic and atraumatic.
Right Ear: External ear normal.
Left Ear: External ear normal.
Nose: Nose normal.
No obvious trauma to head.
Eyes: Conjunctivae are normal. Right eye exhibits no discharge. Left eye exhibits no discharge.
GCS of 15.
Neck: Normal range of motion. Neck supple.
Cardiovascular: Normal rate, regular rhythm and normal heart sounds.
No murmur heard.
Pulmonary/Chest: Effort normal and breath sounds normal. No respiratory distress. She has no rales.
Abdominal: Soft. Bowel sounds are normal. There is no tenderness. There is no rebound and no guarding.
Musculoskeletal: Normal range of motion. She exhibits no edema.
Neurological: She is alert and oriented to person, place, and time. No cranial nerve deficit.
Skin: Skin is warm. No rash noted.
Psychiatric: She has a normal mood and affect. Her behavior is normal.
Nursing note and vitals reviewed.
ED Course
Procedures
MDM
all labs reviewed
imaging results reviewed
EMS information reviewed
medical history reviewed
obtain history from someone other than the patient
Reviewed: History, xray, CT and labs.
RAD ER
Preliminary Result
RAD ER
Preliminary Result
CT Head/Brain Wo Contrast
Final Result
IMPRESSION:
1. No acute intracranial findings.
XR Chest X-ray 1v
Final Result
IMPRESSION:
1. No acute cardiopulmonary process.
Go to
If symptoms worsen
I, , personally performed the services described in this documentation, ascribed in my presence, and it
is both accurate and complete.
ED Dispo
Discharge
Discharge to home/self care.
08/18/16 0850
ED Notes
8/15/2016 22:52
Expand All Collapse All
Bed: CP1
Expected date: 8/15/16
Expected time: 10:52 PM
Means of arrival:
Comments:
Medic 20
57yo F
GLF
Head pain, neck pain, hip pain
No deformity
120/80
54HR
79 Dstick
GCS 15
Denies blood thinners
8/15/2016 23:54
Expand All Collapse All
8/15/2016 23:54
Expand All Collapse All
Pt returned from CT
8/16/2016 00:43
Expand All Collapse All
CASE #3
Code diagnosis codes appropriate for this visit:
CASE #4
Diagnosis
Elbow dislocation, left, initial encounter
Chief Complaint
Arm Injury pt fell landing on L elbow. L elbow deformed. 3+ pulses cap refil <3
sec. full sensation in hand. pt AAAOX4
ED Disposition
Discharge
Discharge to home/self care.
ED Provider Notes
8/24/2016 01:09
Expand All Collapse All
History
Chief Complaint
Patient presents with
• Arm Injury
pt fell landing on L elbow. L elbow deformed. 3+ pulses cap refil <3 sec. full sensation in hand. pt AAAOX4
1A/ 1A 7:42 PM 63 y.o. female who presents to the Christus Trinity Mother France ED with Arm Injury
PCP
Patient was transported via EMS and complains of severe left elbow pain which started about 1 hour ago.
Patient was visiting her mother and she tripped causing to fall impacting bilateral arms on the ground. Sharp
pain is constant worsening with movement and palpation. Denies fever, n/v/d, neck pain, back pain, head
trauma, and LOC.
Family History
Problem Relation Age of Onset
• Stroke Maternal Grandmother
• Heart disease Maternal Grandfather
• Heart disease Father
• Diabetes Brother
• Osteoarthritis Mother
Social History
Substance Use Topics
• Smoking status: Never Smoker
• Smokeless tobacco: Never Used
• Alcohol Use: 0.6 oz/week
1 Cans of beer per week
Comment: occ
Review of Systems
Constitutional: Negative for fever and chills.
HENT: Negative for congestion and rhinorrhea.
Respiratory: Negative for cough and shortness of breath.
Cardiovascular: Negative for chest pain and palpitations.
Gastrointestinal: Negative for nausea, vomiting, abdominal pain and diarrhea.
Genitourinary: Negative for dysuria and hematuria.
Musculoskeletal: Positive for myalgias and arthralgias.
Skin: Negative for rash and wound.
Neurological: Negative for weakness and headaches.
Psychiatric/Behavioral: Negative for confusion and agitation.
Physical Exam
BP 132/70 mmHg | Pulse 76 | Temp(Src) 97.8 °F (36.6 °C) | Resp 12 | Ht 1.626 m (5' 4") | Wt 90.719 kg (200
lb) | BMI 34.31 kg/m2 | SpO2 100%
Physical Exam
Constitutional: She is oriented to person, place, and time. She appears well-developed and well-nourished. No
distress.
HENT:
Head: Normocephalic and atraumatic.
Mouth/Throat: Oropharynx is clear and moist and mucous membranes are normal.
Eyes: Conjunctivae and EOM are normal.
Neck: Normal range of motion. Neck supple.
Cardiovascular: Normal rate, regular rhythm, normal heart sounds and intact distal pulses.
Pulmonary/Chest: Effort normal and breath sounds normal. No respiratory distress. She has no wheezes. She
has no rales.
Abdominal: Soft. Bowel sounds are normal. She exhibits no distension. There is no tenderness. There is no
rebound and no guarding.
Musculoskeletal: She exhibits no edema.
Left elbow: She exhibits decreased range of motion and deformity. Tenderness found.
Neurological: She is alert and oriented to person, place, and time.
Skin: Skin is warm. No rash noted. No erythema.
Psychiatric: She has a normal mood and affect. Her behavior is normal. Judgment and thought content normal.
Nursing note and vitals reviewed.
ED Course
Upper Extremity Dislocation
Date/Time: 8/22/2016 8:54 PM
Performed by:
Authorized by:
Consent:
Consent obtained: Verbal
Risks discussed: Stiffness
Location:
Location: Elbow
Elbow location: L elbow
Elbow dislocation type: posterior
Pre-procedure assessment:
Pre-procedure imaging: X-ray
Imaging findings: dislocation present
Imaging findings: no fracture
Distal perfusion: normal
Sedation:
Sedation type: Deep sedation.
Procedure details:
Manipulation performed: yes
Elbow reduction method: Traction and counter traction
Reduction successful: yes
Reduction confirmed with imaging: yes
Immobilization: Splint
Splint type: Long arm
Supplies used: Plaster, elastic bandage and cotton padding
Post-procedure assessment:
Neurological function: normal
Distal perfusion: normal
Range of motion: improved
Patient tolerance of procedure: Tolerated well, no immediate complications
Sedation
Date/Time: 8/22/2016 8:55 PM
Performed by:
Authorized by:
Consent:
Consent obtained: Verbal
Consent given by: Patient
Indications:
Sedation type: Deep sedation
Sedation purpose: Dislocation reduction
Airway history: None
Procedure necessitating sedation performed by: Physician performing sedation
Pre-sedation assessment:
ASA classification: class 1 - normal, healthy patient
Neck mobility: normal
Mouth opening: 3 or more finger widths
Mallampati score: I - soft palate, uvula, fauces, pillars visible
Immediate pre-procedure details:
Reassessment: Patient reassessed immediately prior to procedure
Reviewed: vital signs
Verified: bag valve mask available, emergency equipment available, intubation equipment available, IV
patency confirmed, oxygen available, reversal medications available and suction available
Procedure details (see MAR for exact dosages):
Preoxygenation: Nasal cannula
Sedation: Etomidate
Intra-procedure monitoring: Blood pressure monitoring, cardiac monitor, frequent vital sign checks,
frequent LOC assessments, continuous capnometry and continuous pulse oximetry
Intra-procedure events: none
Sedation end time: 8/22/2016 9:17 PM
Post-procedure details:
Attendance: Constant attendance by certified staff until patient recovered
Recovery: Patient returned to pre-procedure baseline
Patient tolerance: Tolerated well, no immediate complications
MDM
Re-Evaluations
8:50 PM
Patient is informed about imaging results and need for ortho reduction. She verbalizes understanding and has
no new complaints.
9:54 PM
Patient is informed about consult with ortho and need for follow up. She verbalizes understanding and has no
new complaints.
Consults
9:52 PM
Consult with Dr. (CTMF Ortho). Recommends follow up at the ortho office.
Discussed with patient results of this encounter and plan of care. Pt understands and agrees.
PRESCRIPTIONS:
New Prescriptions
ACETAMINOPHEN-CODEINE (TYLENOL #3) 300-30 Take 1-2 tablets by mouth every 6 (six) hours as
MG TABLET needed for Pain
I, personally performed the services described in this documentation, ascribed in my presence, and it
is both accurate and complete.
ED Dispo
Discharge
ED Notes
8/22/2016 19:34
Expand All Collapse All
Bed: TR2
Expected date: 8/22/16
Expected time: 7:32 PM
Means of arrival: EMS - ETMC
Comments:
Unit 838
63 F- Fall dislocated left elbow obvious deformity- CMS intact
GCS15, RTS: 12, 78SR, 131/67, 95%RA Fent 100mcg
8/22/2016 19:56
Expand All Collapse All
pt fell landing on L elbow. L elbow deformed. 3+ pulses cap refil <3 sec. full sensation in hand. pt
AAAOX4. Pt medicated for pain PTA by EMS state pain is 5/10 at this time