ED Coding Test

Diagnoses
MVC (motor vehicle collision)

Chest wall contusion, unspecified laterality, initial
encounter
Multiple abrasions
Laceration of hand, right, initial encounter
Sprain of right ankle, unspecified ligament, initial
encounter
Contusion of right foot, initial encounter
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.
Condition at discharge good.
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.
Past Medical History

Diagnosis Date
• Cancer
• Thyroid disease
Past Surgical History

Procedure Laterality Date
• Thyroid surgery
History reviewed. No pertinent family history.
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.
MEDS GIVEN IN ECC:

All Medication Orders
Start Ordered Status Ordering Provider
08/20/16 08/20/16 HYDROcodone-acetaminophen Last MAR action:
1040 1038 (NORCO) 10-325 MG per tablet 1 Given
tablet Once
Route: Oral Ordered Dose: 1 tablet
08/20/16 08/20/16 carisoprodol (SOMA) tablet 350 mg Last MAR action:

1040 1038 Once Given
Route: Oral Ordered Dose: 350 mg
08/20/16 08/20/16 HYDROmorphone (DILAUDID) Last MAR action:

1015 1012 injection 1 mg Once Given
Route: Intravenous Ordered Dose: 1
mg
08/20/16 08/20/16 iohexol (OMNIPAQUE 300) 300 Last MAR action:

0954 0955 MG/ML injection 100 mL IMG once Given
as needed
Route: Intravenous Ordered Dose:
100 mL
08/20/16 08/20/16 morphine 4 mg/mL injection (PF) 4 Last MAR action:

0841 0843 mg Every 10 min PRN Given
mg
LABS FOR THIS VISIT:

Hospital Encounter on 08/20/16
CBC
Collection Time: 08/20/16 8:52 AM
Result Value Ref Range
White Blood Cells 12.1 (H) 4.5 - 11.0 k/uL
RBC 5.05 4.00 - 5.20 mil/uL
Hemoglobin 10.7 (L) 12.0 - 16.0 gm/dL
Hematocrit 36.0 36.0 - 46.0 %
RDW 17.9 (H) 11.5 - 14.5 %
MCH 21.3 (L) 26.0 - 34.0 pg
MCHC 29.8 (L) 31.0 - 37.0 gm/dL
MCV 71.2 (L) 79.3 - 94.8 fL
MPV 7.3 (L) 7.5 - 10.7 um3
Platelets 272 150 - 450 k/uL
Segs Relative 81 (H) 36 - 66 %
Lymphocytes Relative 9 (L) 24 - 44 %
Monocytes Relative 10 0 - 10 %
Eosinophils Relative 0 0-5%
Basophils Relative 0 0-2%
Anisocytosis Slight
Hypochromia 3+
Microcytosis 2+ (A)
Elliptocytes Slight
Basic metabolic panel
Glucose 97 70 - 110 mg/dL
BUN 13 7 - 17 mg/dL
Creatinine, Ser 0.58 0.50 - 1.40 mg/dL
Sodium 137 137 - 145 mmol/L
Potassium 4.0 3.5 - 5.3 mmol/L
CO2 - Bicarbonate 26.8 22.0 - 30.0 mmol/L
Chloride 104 100 - 108 mmol/L
Anion Gap 6 (L) 8 - 16 mmol/L
BUN/Creatinine Ratio 22 (H) 12 - 20
Osmolality Calc 274 (L) 275 - 295
Calcium 9.6 8.4 - 10.2 mg/dL
GFR MDRD Non Af Amer 115 >=60 mL/min
GFR MDRD Af Amer 139 >=60 mL/min
Protime-INR
Protime 12.8 11.4 - 15.3 second(s)
INR 1.0 0.8 - 1.2 second(s)
Partial Thromboplastin time
PTT 26.3 23.5 - 36.3 second(s)
Phosphorus
Phosphorus 2.8 2.5 - 4.5 mg/dL
Magnesium
Magnesium 1.9 1.6 - 2.3 mg/dL
Amylase
Amylase 60 30 - 110 IU/L
HCG Serum Qual for females of childbearing age.
hCG Neg
Troponin I
Troponin I <0.012 0.000 - 0.120 ng/mL
IMAGES FOR THIS VISIT:

CT Chest Abdomen Pelvis W Contrast
Final Result
Impression:
Chest:
No acute injury.
Abdomen/pelvis:
No acute injury.
CT Cervical Spine Wo Contrast

Final Result
IMPRESSION:
1. No CT evidence of injury to the cervical spine.
2. C4-C5 central disc protrusion with minimal narrowing of the
central canal..
X-ray Foot right 3 views

Final Result
IMPRESSION:
1. No acute skeletal abnormality.
X-ray ankle right 2 views

Final Result
IMPRESSION:
1. No acute skeletal abnormality.
Re-Evaluations
9:40 AM
Discussed with patient results of this encounter and plan of care. Pt understands and agrees.
DIAGNOSIS FOR THIS VISIT:

1. MVC (motor vehicle collision)
2. Chest wall contusion, unspecified laterality, initial encounter
3. Multiple abrasions
4. Laceration of hand, right, initial encounter
5. Sprain of right ankle, unspecified ligament, initial encounter
6. Contusion of right foot, initial encounter
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
INSTRUCTED TO FOLLOW UP WITH:

In 2 days
If symptoms worsen
I, , am scribing for and in the presence of, MD.
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
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
Pt states pain continues without relief by pain meds. Will monitor
RN 8/20/2016 10:03
Patient transported to CT
RN 8/20/2016 10:05
Patient returned to room. No change in status.
All Flowsheet Data (all recorded)

Trauma Activation/Treatment PTA
None
CASE #1
Code diagnoses for this visit:
Code Professional CPTs:
Code Facility CPTs:

CASE #2
Diagnoses
Respiratory acidosis
Respiratory failure, unspecified chronicity,
unspecified whether with hypoxia or hypercapnia
Dehydration
Hypotension, unspecified hypotension type
Chief Complaint
Respiratory Distress sent to ER for unresponsive and difficulty breathing today from nsg
home
ED Disposition
Admit
will be admitted to Dr - ICU.
ED Provider Notes
8/26/2016 20:19
History
Chief Complaint
• 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.
BP=112/75, HR=50s-120s, o2 sats at 98% on bipap

Diagnosis Date
• COPD (chronic obstructive pulmonary disease)
• Gastrostomy hemorrhage
• Anxiety
• Hypertension
• Heart failure
• Atrial fibrillation
• Pulmonary embolism
• Neuropathy, alcoholic
• Chronic respiratory failure with hypercapnia
• Chronic respiratory failure with hypoxia
• Constipation
• Gastrostomy hemorrhage
• Muscle wasting and atrophy, not elsewhere classified, unspecified
site
• Supraventricular tachycardia
• Heart failure

• Gastrostomy tube placement and removal
Family History
Problem Relation Age of Onset
• Hypertension Brother
Social History
• 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.
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.
Cardiovascular: Regular rhythm and normal heart sounds. Tachycardia present.
No murmur heard.
Pulmonary/Chest: No respiratory distress. He has no rales.
Poor airway movement
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.
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%.
12:46 PM BP=74/56, HR=132, o2 sats at 93%.
Central Line Placement

Date/Time: 8/26/2016 12:51 PM
Performed by:
Authorized by:
Consent:
Consent obtained: Emergent situation
Pre-procedure details:
Hand hygiene: Hand hygiene performed prior to insertion
Sterile barrier technique: All elements of maximal sterile technique followed
Skin preparation: 2% chlorhexidine
Skin preparation agent: Skin preparation agent completely dried prior to procedure
Procedure details:
Location: R femoral
Patient position: Flat
Procedural supplies: Triple lumen
Catheter size: 7 Fr
Landmarks identified: yes
Ultrasound guidance: no
Number of attempts: 1
Successful placement: yes
Post-procedure: Dressing applied and line sutured
Assessment: Blood return through all ports
Comments:
12:56 PM BP=93/73, HR=119, o2 sats at 90%.
1:00 PM HR=124, BP=91/70, 02 sats at 87%.
1:07 PM BP=85/67, HR=118, o2 sats at 94%.

Critical Care
Performed by:
Authorized by: Critical care provider statement:
Critical care time (minutes): 90
Critical care time was exclusive of: Separately billable procedures and treating other patients and
teaching time
Critical care was necessary to treat or prevent imminent or life-threatening deterioration of the following
conditions: Respiratory failure, circulatory failure and dehydration
Critical care was time spent personally by me on the following activities: Blood draw for specimens,
obtaining history from patient or surrogate, development of treatment plan with patient or surrogate,
discussions with consultants, evaluation of patient's response to treatment, examination of patient,
interpretation of cardiac output measurements, ordering and performing treatments and interventions,
ordering and review of laboratory studies, ordering and review of radiographic studies, re-evaluation of
patient's condition, review of old charts and ventilator management
MDM
all labs reviewed
ECG reviewed
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:
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
08/26/16 08/26/16 propofol (DIPRIVAN) infusion Last MAR action:

1253 1256 Continuous PRN New Bag/Started
Route: Intravenous
08/26/16 08/26/16 calcium chloride 10 % injection Last MAR action:

1235 1236 Once as needed Given
Route: Intravenous

Arterial Blood Gas W/Lactate & CCP
Collection Time: 08/26/16 12:35 PM
pH, Arterial 7.1500
pO2, Arterial 145.7000
pCO2, Arterial 143.7000
HCO3, Arterial 48.9 (H) 22 - 26 mmol/L
Base Excess, Arterial 15.80 (H) 2--2
COHb 1.40 0.5 - 2.5%
O2Hb 95.40 95 - 99 %
MetHb 1.10 0.4 - 1.5 %
HGB 10.40 (L) 14 - 18 g/dL
O2 Sat, Arterial 97.80 75.0-99.0
Sodium 141.60 135 - 148 mmol/L
Potassium, Bld 4.27 3.5 - 4.5 mmol/L
Chloride 90.70 (L) 98 - 107 mmol/L
Ionized Calcium, Art 1.22 1.120-1.320
Lactate, Art 1.00 0.4 - 2.2 mmol/L
Site: r radial
Allen's Test Acceptable
Time drawn: 1230
O2 Device: nrb
FIO2: 1.00
Who notified: dr price
Time notified: 1240
How notified: person
Baro. Pres: 756.6 mmHg
Draw Date 20160826
Draw Time 123703
Complete Blood Count
RBC 3.50 (L) 4.50 - 5.90 mil/uL
Hemoglobin 10.2 (L) 13.5 - 17.5 gm/dL
Hematocrit 33.1 (L) 41.0 - 53.0 %
RDW 16.5 (H) 11.5 - 14.5 %
MCH 29.1 26.0 - 34.0 pg
MCHC 30.8 (L) 31.0 - 37.0 gm/dL
MCV 94.4 79.3 - 94.8 fL
MPV 8.5 7.5 - 10.7 um3
Segs Relative 86 (H) 36 - 66 %
Bands Relative 9 (H) 0-6%
Lymphocytes Relative 3 (L) 24 - 44 %
Comprehensive metabolic panel
BUN 33 (H) 9 - 20 mg/dL
Creatinine, Ser 0.42 (L) 0.50 - 1.40 mg/dL
Chloride 89 (L) 100 - 108 mmol/L
Calcium 9.0 8.4 - 10.2 mg/dL
Protein, Total 6.8 6.3 - 8.2 gm/dL
Albumin/Globulin Ratio 0.9 (L) 1.1 - 2.0
Albumin 3.3 (L) 3.9 - 5.0 gm/dL
AST 24 17 - 59 IU/L
ALT 21 21 - 72 IU/L
Alkaline Phosphatase 127 (H) 38 - 126 IU/L
Total Bilirubin 0.8 0.2 - 1.3 mg/dL
Sodium 146 (H) 137 - 145 mmol/L
CO2 - Bicarbonate 42.8 (AA) 22.0 - 30.0 mmol/L
Anion Gap 14 8 - 16 mmol/L
Osmolality Calc 298 (H) 275 - 295
BNP
BNP 844 (H) <=300 pg/mL
Procalcitonin
Procalcitonin 1.63 (H) <=0.50 ng/mL
Partial Thromboplastin Time
PTT 45.1 (H) 23.5 - 36.3 second(s)
Protime-INR
Protime 37.4 (H) 11.4 - 15.3 second(s)
INR 3.7 (H) 0.8 - 1.2 second(s)
Troponin I
Troponin I 0.022 0.000 - 0.120 ng/mL

X-ray Portable Chest 1 view
Final Result
Impression:Supportive tubes and lines in place as above with
evidence of chronic lung disease as well as superimposed acute
moderate pulmonary congestion
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.

1. Respiratory acidosis
2. Respiratory failure, unspecified chronicity, unspecified whether with hypoxia or hypercapnia
3. Dehydration
4. Hypotension, unspecified hypotension type
I, , am scribing for and in the presence of, MD.
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
Bed: TR1
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

None
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
Line Med Linked Time Comment

[REMOVED] Peripheral IV 08/26/16 Right Wrist 08/26/2016 1316
Action Dose Rate Route Site Time Comment

New Bag/Started 2,000 mL 2,000 mL/hr Intravenous 08/26/2016 1316
Completed 0 mL 0 mL/hr Intravenous 08/26/2016 1445
propofol (DIPRIVAN) infusion

Total time: N/A
Running start: 08/26/2016 1358 Running stop: Not Stopped
Associated diagnoses: Therapeutic class: Analgesics & Anesthetics


New Bag/Started 40 mcg/kg/min 12 mL/hr Intravenous Right Arm 08/26/2016 1358
vancomycin 750 mg in sodium chloride 0.9 % 250 mL IVPB

Total time: 8 Hours 6 Minutes
Associated diagnoses: Therapeutic class:

[REMOVED] Central Venous Catheter 08/26/16 08/26/2016 1520
Right Femoral (Distal)
Unlinked 08/28/2016 0350

New Bag/Started 750 mg 125 mL/hr Intravenous 08/26/2016 1520
Completed 0 mg 0 mL/hr Intravenous 08/26/2016 1727
New Bag/Started 750 mg 125 mL/hr Intravenous 08/28/2016 0350 limited iv access
due to blood
products
albumin (human) 25% IVPB 25 g
Associated diagnoses: Therapeutic class: Hematological Agents

Right Femoral (Proximal)

New Bag/Started 25 g 200 mL/hr Intravenous 08/26/2016 1550 ER pt just got to
unit
Completed 0g 0 mL/hr Intravenous 08/26/2016 1624
New Bag/Started 25 g 200 mL/hr Intravenous 08/26/2016 2034
piperacillin-tazobactam (ZOSYN) IVPB 3.375 g / dextrose 50 mL (premixed)

Total time: N/A
Running start: 08/26/2016 1550 Running stop: Not Stopped
Associated diagnoses: Therapeutic class: Anti-Infective Agents

Unlinked 08/29/2016 0035
[REMOVED] PICC Line 08/27/16 Left Basilic (White 08/31/2016 0824
Port)

New Bag/Started 3.375 g 12.5 mL/hr Intravenous 08/26/2016 1550
Paused 0g 0 mL/hr Intravenous 08/31/2016 1516 PT/OT eval
Restarted 3.375 g 12.5 mL/hr Intravenous 08/31/2016 1600
lactated ringers infusion


New Bag/Started 125 mL/hr Intravenous 08/26/2016 1551 ER pt just got to
ICU
New Bag/Started 125 mL/hr Intravenous 08/26/2016 2354
Stopped 0 0 mL/hr Intravenous 08/27/2016 0804
Rate/Dose 25 mL/hr Intravenous 08/27/2016 1033
Change
Change
Change
Paused 0 0 mL/hr Intravenous 08/27/2016 2130
azithromycin (ZITHROMAX) 500 mg in sodium chloride 0.9 % 250 mL IVPB


Unlinked

phenylephrine (NEO-SYNEPHRINE) 10 mg in sodium chloride 0.9 % 250 mL infusion



Bolus from Bag 50 mcg/min 75 mL/hr Intravenous 08/26/2016 2215
New Bag/Started 50 mcg/min 75 mL/hr Intravenous 08/27/2016 0111
Rate/Dose 43.333 mcg/min 65 mL/hr Intravenous 08/27/2016 1033
Change
Change
Change
Change
Stopped 0 mcg/min 0 mL/hr Intravenous 08/27/2016 1400
fentaNYL (SUBLIMAZE) 50 mcg/mL infusion


[REMOVED] PICC Line 08/27/16 Left Basilic (Grey 08/31/2016 1027
Port)

New Bag/Started 25 mcg/hr 0.5 mL/hr Intravenous 08/26/2016 2222
Rate/Dose 50 mcg/hr 1 mL/hr Intravenous 08/27/2016 1323
Change
Completed 0 mcg/hr 0 mL/hr Intravenous 08/31/2016 1027
sodium phosphate 15 mmol in sodium chloride 0.9 % 100 mL IVPB

Total time: 2 Hours

Right Femoral (Distal)

New Bag/Started 15 mmol 50 mL/hr Intravenous 08/27/2016 0440
Completed 0 mmol 0 mL/hr Intravenous 08/27/2016 0640
magnesium sulfate IVPB 2 g
Total time: 1 Hour

Right Femoral (Medial)

potassium chloride 40 mEq in 100 mL IVPB

Total time: 2 Hours

Right Femoral (Medial)

New Bag/Started 40 mEq 50 mL/hr Intravenous 08/27/2016 0528
Completed 0 mEq 0 mL/hr Intravenous 08/27/2016 0728
potassium chloride 40 mEq in 100 mL IVPB


Unlinked

sodium phosphate 15 mmol in sodium chloride 0.9 % 100 mL IVPB

Total time: 2 Hours

Unlinked

New Bag/Started 15 mmol 50 mL/hr Intravenous 08/28/2016 0952
Completed 0 mmol 0 mL/hr Intravenous 08/28/2016 1152
sodium chloride 0.9% infusion


[REMOVED] PICC Line 08/27/16 Left Basilic 08/31/2016 1027
(Purple Port)

Paused 0 0 mL/hr Intravenous 08/31/2016 1027
vancomycin 750 mg in sodium chloride 0.9 % 250 mL IVPB


Unlinked 08/29/2016 0605

New Bag/Started 750 mg 125 mL/hr Intravenous 08/29/2016 0035 missing med
New Bag/Started 750 mg 125 mL/hr Intravenous 08/30/2016 1616 given as soon as
available from
pharmacy
propofol (DIPRIVAN) infusion


Unlinked 08/29/2016 2216
(Purple Port)

New Bag/Started 5 mcg/kg/min 1.6 mL/hr Intravenous 08/28/2016 1641
Rate/Dose 10 mcg/kg/min 3.2 mL/hr Intravenous 08/28/2016 1655
Change
Change
Change
Stopped 0 mcg/kg/min 0 mL/hr Intravenous 08/29/2016 0740
Restarted 25 mcg/kg/min 7.9 mL/hr Intravenous 08/29/2016 1208
Change
Change
Change
Change
New Bag/Started 35 mcg/kg/min 11 mL/hr Intravenous 08/31/2016 0523
Change
Completed 0 mcg/kg/min 0 mL/hr Intravenous 08/31/2016 1027
fluconazole (DIFLUCAN) IVPB 200 mg


Unlinked

fluconazole (DIFLUCAN) IVPB 100 mg


(Purple Port)


Total time: 1 Hour

Unlinked 08/30/2016 0545


Total time: 1 Hour

Unlinked

magnesium sulfate 1 g/100 mL dextrose 5 % (premixed) IVPB



calcium gluconate 1 g in sodium chloride 0.9 % 100 mL IVPB

Total time: 1 Hour


CASE #2
Code the diagnosis codes appropriate for this visit:
Code the Professional CPTs for the ED visit
Code the Facility 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
ED Provider Notes
8/18/2016 08:50
History
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.
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.

Diagnosis Date
• Hypertension
• Myocardial infarction
• CAD (coronary artery disease)
• HLD (hyperlipidemia)
• Lumbar stenosis
• Arthritis
• Disc prolapse
• History of torn meniscus of left knee
• Diabetes mellitus
• Coronary artery disease
• Shortness of breath
• Anxiety

• Coronary angioplasty with stent
placement
• Hip replacement left
2013
• Chg radn treatment aid(s) interm
• Joint replacement
left hip
• Back surgery
• Cardiac surgery 2011
Triple bipass
Family History
• Coronary artery disease
• Diabetes
• Stroke
• Cancer
grand mother had breast cancer
• Hyperlipidemia
• Diabetes Mother
• Hypertension Mother
• Diabetes Father
• Hypertension Father
Social History
• Smoking status: Current Every Day Smoker -- 0.50 packs/day for 20
years
Types: Cigarettes
Comment: more than 30 yrs
• Alcohol Use: No
Review of Systems
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.
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
distress. Cervical collar in place.
HENT:
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.
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.
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.
ED Course
Procedures
MDM
all labs reviewed
Reviewed: History, xray, CT and labs.
MEDS GIVEN IN ECC:

08/16/16 08/16/16 HYDROmorphone (DILAUDID) Acknowledged
0050 0046 injection 1 mg Once
mg
08/16/16 08/16/16 ondansetron (ZOFRAN) injection 4 Acknowledged

0050 0046 mg Once
mg
08/15/16 08/15/16 HYDROmorphone (DILAUDID) Last MAR action:

2315 2313 injection 1 mg Once Given
mg
08/15/16 08/15/16 ondansetron (ZOFRAN) injection 4 Last MAR action:

2315 2313 mg Once Given
mg

Complete Blood Count
RBC 4.33 4.00 - 5.20 mil/uL
Hemoglobin 13.4 12.0 - 16.0 gm/dL
Hematocrit 40.3 36.0 - 46.0 %
RDW 14.5 11.5 - 14.5 %
MCH 31.0 26.0 - 34.0 pg
MCHC 33.2 31.0 - 37.0 gm/dL
MCV 93.2 79.3 - 94.8 fL
MPV 7.9 7.5 - 10.7 um3
Segs Relative 62 36 - 66 %
Lymphocytes Relative 29 24 - 44 %
Basic Metabolic Panel
BUN 20 (H) 7 - 17 mg/dL
Creatinine, Ser 0.67 0.50 - 1.40 mg/dL
Sodium 142 137 - 145 mmol/L
Chloride 110 (H) 100 - 108 mmol/L
CO2 - Bicarbonate 22.9 22.0 - 30.0 mmol/L
Anion Gap 9 8 - 16 mmol/L
Osmolality Calc 286 275 - 295
Calcium 8.8 8.4 - 10.2 mg/dL
Protime-INR
Protime 12.9 11.4 - 15.3 second(s)
INR 1.0 0.8 - 1.2 second(s)

RAD ER
Preliminary Result
RAD ER
Preliminary Result
RAD ER
Preliminary Result
CT Lumbar Spine Wo Contrast

Final Result
IMPRESSION:
1. No CT evidence of acute injury to the lumbar spine.
CT dose reduction techniques, including automated exposure control,

were utilized to minimize radiation.
RAD ER
Preliminary Result
CT Thoracic Spine Wo Contrast

Final Result
IMPRESSION:
1. No CT evidence of acute injury to the thoracic spine.
CT Cervical Spine Wo Contrast

Final Result
IMPRESSION:
1. No CT evidence of acute injury to the cervical spine.
2. Multilevel cervical spondylosis.
CT Head/Brain Wo Contrast
Final Result
IMPRESSION:
1. No acute intracranial findings.
Automated exposure control CT radiation dose reduction techniques

were used.
XR Chest X-ray 1v
Final Result
IMPRESSION:
1. No acute cardiopulmonary process.
X-ray Portable pelvis 1 view

Final Result
IMPRESSION:
1. No acute osseous abnormality.
Please note that a single frontal radiograph of the pelvis is

relatively insensitive for nondisplaced pelvic fractures. CT can be
obtained if there is clinical concern for radiographically occult
fracture.
CONSULT AND RE-EVAL:

12:47 AM Discussed results from today's visit and plans of discharge- agrees with plan of care.

1. Concussion, with loss of consciousness of unspecified duration, initial encounter
2. Back pain, unspecified back pain laterality, unspecified location
Schedule an appointment as soon as possible for a visit

If symptoms worsen
Go to
If symptoms worsen
I, am scribing for and in the presence of MD.
I, , personally performed the services described in this documentation, ascribed in my presence, and it
is both accurate and complete.
ED Dispo
Discharge
08/18/16 0850
ED Notes
8/15/2016 22:52
Bed: CP1
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
Pt in Ct via stretcher with nurse.
8/15/2016 23:54
Pt returned from CT
8/16/2016 00:43
ERMD at bedside for reeval.

None
CASE #3
Code diagnosis codes appropriate for this visit:
Code all Professional CPTs:
Code all Facility CPTs
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
ED Provider Notes
8/24/2016 01:09
History
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
The history is provided by the patient.
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.

Diagnosis Date
• Abnormal Pap smear
• Abnormal Pap smear of cervix
• Toncil
• Ankle fusion 1998
had this surgery x2
• Foot fusion 2013
Family History
• Stroke Maternal Grandmother
• Heart disease Maternal Grandfather
• Heart disease Father
• Diabetes Brother
• Osteoarthritis Mother
Social History
• Smoking status: Never Smoker
• Alcohol Use: 0.6 oz/week
1 Cans of beer per week
Comment: occ
Review of Systems
HENT: Negative for congestion and rhinorrhea.
Respiratory: Negative for cough and shortness of breath.
Cardiovascular: Negative for chest pain and palpitations.
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
distress.
HENT:
Mouth/Throat: Oropharynx is clear and moist and mucous membranes are normal.
Eyes: Conjunctivae and EOM are normal.
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.
ED Course
Upper Extremity Dislocation
Date/Time: 8/22/2016 8:54 PM
Performed by:
Authorized by:
Consent:
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
Sedation
Date/Time: 8/22/2016 8:55 PM
Performed by:
Authorized by:
Consent:
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
Attendance: Constant attendance by certified staff until patient recovered
Recovery: Patient returned to pre-procedure baseline
Patient tolerance: Tolerated well, no immediate complications
MDM

Reviewed: History and xray.
Case discussed with ortho.
MEDS GIVEN IN ECC:

08/22/16 08/22/16 propofol (DIPRIVAN) injection Last MAR
2051 2053 Once as needed action: Given
Route: Intravenous
08/22/16 08/22/16 HYDROmorphone (DILAUDID) Last MAR

1950 1946 injection 1 mg Once action: Given
mg

No results found for this visit on 08/22/16.
X-ray Elbow left 2 views
Final Result
IMPRESSION:
1. Dislocation left elbow with posterior displacement of the
proximal radius and ulna in relationship to the distal humerus. No
fracture is identified.
XR Forearm left 2v Post Reduction (Results Pending)
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.

1. Elbow dislocation, left, initial encounter
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
Schedule an appointment as soon as possible for a visit

Follow Up
I, am scribing for and in the presence of
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
Bed: TR2
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
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

None
CASE #4
Code all diagnoses relevant to this encounter
Code all professional CPTs
Code all facility CPTs

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Diagnoses

MVC (motor vehicle collision)

Condition at discharge good.

Past Medical History

Past Surgical History

History reviewed. No pertinent family history.

MEDS GIVEN IN ECC:

08/20/16 08/20/16 carisoprodol (SOMA) tablet 350 mg Last MAR action:

08/20/16 08/20/16 HYDROmorphone (DILAUDID) Last MAR action:

08/20/16 08/20/16 iohexol (OMNIPAQUE 300) 300 Last MAR action:

08/20/16 08/20/16 morphine 4 mg/mL injection (PF) 4 Last MAR action:

LABS FOR THIS VISIT:

IMAGES FOR THIS VISIT:

CT Cervical Spine Wo Contrast

X-ray Foot right 3 views

X-ray ankle right 2 views

DIAGNOSIS FOR THIS VISIT:

INSTRUCTED TO FOLLOW UP WITH:

I, , am scribing for and in the presence of, MD.

Discharge to home/self care.

Condition at discharge good.

Pt states pain continues without relief by pain meds. Will monitor

Patient returned to room. No change in status.

All Flowsheet Data (all recorded)

Code Professional CPTs:

Code Facility CPTs:

will be admitted to Dr - ICU.

BP=112/75, HR=50s-120s, o2 sats at 98% on bipap

Past Surgical History

12:46 PM BP=74/56, HR=132, o2 sats at 93%.

Central Line Placement

1:00 PM HR=124, BP=91/70, 02 sats at 87%.

1:07 PM BP=85/67, HR=118, o2 sats at 94%.

08/26/16 08/26/16 propofol (DIPRIVAN) infusion Last MAR action:

08/26/16 08/26/16 calcium chloride 10 % injection Last MAR action:

Hospital Encounter on 08/26/16

IMAGES FOR THIS VISIT:

DIAGNOSIS FOR THIS VISIT:

I, , am scribing for and in the presence of, MD.

All Flowsheet Data (all recorded)

Line Med Linked Time Comment

Action Dose Rate Route Site Time Comment

propofol (DIPRIVAN) infusion

Line Med Linked Time Comment

Action Dose Rate Route Site Time Comment

vancomycin 750 mg in sodium chloride 0.9 % 250 mL IVPB

Line Med Linked Time Comment

Action Dose Rate Route Site Time Comment

Line Med Linked Time Comment

Action Dose Rate Route Site Time Comment

piperacillin-tazobactam (ZOSYN) IVPB 3.375 g / dextrose 50 mL (premixed)

Line Med Linked Time Comment

Action Dose Rate Route Site Time Comment

lactated ringers infusion

Line Med Linked Time Comment

azithromycin (ZITHROMAX) 500 mg in sodium chloride 0.9 % 250 mL IVPB

Line Med Linked Time Comment

Action Dose Rate Route Site Time Comment

phenylephrine (NEO-SYNEPHRINE) 10 mg in sodium chloride 0.9 % 250 mL infusion