APPENDIX A: EAST MCT Outcomes after acute care surgery and trauma care in incarcerated individuals Trauma Diagnoses: (select all that apply)
|
|
- Melina Warner
- 5 years ago
- Views:
Transcription
1 APPENDIX A: EAST MCT Outcomes after acute care surgery and trauma care in incarcerated individuals Trauma Diagnoses: (select all that apply) Neurologic Injuries Traumatic Brain Injury Epidural Subdural Subarachnoid Diffuse axonal injury Concussion Other Spine injuries Cervical spine Thoracic spine Lumbar spine Other Paralysis (circle) Yes No Orthopedic injuries Fracture Location(s) Dislocation Location(s) Other Location(s) Intra-abdominal injuries (check all) Liver laceration Grade: Spleen laceration Grade: Kidney laceration Grade: Large bowel injury Small bowel injury Bladder injury Other organ injury Other Thoracic Injuries (check all) Rib fractures Hemothorax Pneumothorax Sternal fracture Cardiac injury Other Acute Surgical Diagnoses: (select all that apply) General Surgery Acute appendicitis (circle) Perforated Non-perforated Cholecystitis (circle) acute chronic Symptomatic cholelithiasis Choledocholithiasis Cholangitis Gallstone pancreatitis Alcoholic pancreatitis Diverticulitis (circle) With abscess With peritonitis Esophageal Perforation GI Bleed(circle): Upper Lower Bowel obstruction(circle): Large Small Volvulus (circle) Sigmoid Cecal Small bowel Gastric/duodenal ulcer(circle): Bleeding Perforation Intestinal perforation (circle): Large Small Hernia (circle) Ventral Inguinal Femoral Other : (circle) Reducible Incarcerated Strangulated Unknown Soft tissue infections Abscess Necrotizing infection Location Perianal disease Acute limb ischemia Aneurysmal disease Other Other Injuries (check all) Vascular injuries Location Laceration Location Facial fracture Other
2 TITLE: Outcomes after acute care surgery and trauma care in incarcerated individuals: a prospective observational trial Data Element Definition / Instructions Demographics: Case Number Age Biological sex Race Height Weight Payor Assigned number by institution, Ordered chronologically from oldest (1) to newest Free text entry of patient s age, age 16 and older at time of admission Select patient s biological sex from the following: Male Female Select patient s race from the following: White Black Hispanic Asian Other Free text entry of patient s height in cm Free text entry of patient s weight in kg Primary payor identified for the individual patient. Usually identified by business manager of surgery department. Medical History: Comorbidities Recorded (Yes, No, NR = Not Recorded) for all of the following: Obesity Hypertension Diabetes mellitus (includes type I and type II) Drug use disorder, including alcohol use disorder Mental health condition COPD
3 CHF Dementia Anticoagulant use HIV Hep C History of Tobacco use Cancer o Type (free text) Other (free text) Pre-hospital data: Treatment location prior to presentation Duration of symptoms prior to arrival Similar presentation Record location of patient prior to presentation to definitive hospital Prison Jail Outside emergency department Outside inpatient hospital Other (free text) Record approximate time elapsed since injury or symptom onset to presentation to initial health facility outside correctional facility. Circle <12 hours, hours, >24 hours, or unknown. Was the patient previously evaluated for same injury or for same problem/symptoms? Yes, No, NR = Not Recorded. Incarceration Data: State of incarceration Location of incarceration - arrival Location of incarceration - discharge Specifies in which state patient is currently incarcerated in order to classify by structure/model of correctional healthcare. Information on state of incarceration will only be used to classify by model of care. Use two letter abbreviation Record location of incarceration prior to presentation. Prison Jail Unspecified Record location of incarceration at discharge from hospital or ED Prison Jail Unspecified
4 Injury Data (if applicable): ISS ED GCS AIS by body region Mechanism of Injury (MOI) Intent of Injury Free text entry of Patient s calculated ISS (ISS = Injury severity score, range 1-75) Free text entry of patient s initial or first recorded GCS (Glasgow Comas Scale; range 3 to 15; composed of three parts: eye, verbal, motor). 3 is the worst. Free text entry for head, spine, chest, abdomen, extremity upon presentation (0=no injury, 1=minor, 2=moderate, 3=serious, 4=severe, 5=critical, 6=unsurvivable) Select mechanism of injury from the following: Fall MVC (Motor Vehicle Collision) Pedestrian Gunshot wound Machine Assault o Weapon - Choose: hand/foot blunt object free text Other (free text) Record intent of injury, if known Intentional (yes/no) o Self-harm o Not self-harm Unintentional (yes/no) o Occupational injury o Not occupational injury Unspecified Admission Data (if applicable): Admitting Service Select admitting service: Trauma Orthopedic Surgery Neurosurgery Cardiothoracic surgery Medicine ENT Plastic surgery
5 General surgery (non-trauma) Other (free text) Post ED Disposition Consulting Service(s) Select patient s hospital destination following emergency department consultation: Floor Intensive Care Unit (ICU) Operating Room Step-down Unit Discharge Other (free text) Record if any of the following were consulted during the patient s primary admission (Yes, No, NR = Not Recorded. Trauma surgery Orthopedic surgery Neurosurgery Cardiothoracic surgery Medicine ENT Plastic surgery General surgery (non-trauma) Psychiatry Diagnoses: Trauma Diagnoses Acute Surgical Diagnoses Appendix I - Select all that apply. If unknown, leave blank. Specify grade of solid organ injury if known. Spine injuries include compression, herniation, spinal cord injury, or fracture of any part of the vertebrae including spinous, transverse, or articular process(es). Paralysis defined as loss of motor function of any limb due to spinal injury, may be temporary or permanent. Appendix I - Select all that apply. If unknown, leave blank. Select diagnosis whether or not surgery was performed. Procedures (if applicable): Need for Operation (Need OR) Time to first operation from admission Record if patient sent to operating room for any procedure. Yes, No, NR = Not Recorded. Free text number of hours from the time of presentation to the ED to entry into an operating room suite. Round to the nearest whole hour.
6 Number of Operations (NumOps) CPT of Procedure 1 CPT of Procedure 2 CPT of Procedure 3 CPT of Procedure 4 Time to fixation Other interventions Admission Data: Hospital length of stay ICU length of stay Transfusion Number of operations during length of stay. Free text entry of number up to 12 patient procedures. CPT code of initial procedure performed (if applicable) CPT code of 2nd procedure performed (if applicable) CPT code of 3rd procedure performed (if applicable) CPT code of 4th procedure performed (if applicable) If patient sustained orthopedic fracture requiring surgical intervention, record free text number of hours from the time of presentation to the ED to entry into an operating room suite for fixation (either definitive or temporary). Report the first procedure only. Round to the nearest whole hour. Recorded (Yes, No, NR = Not Recorded) for the following: Chest tube insertion Check indication(s) Central line insertion Tracheostomy Traction (orthopedic injury) Casting (orthopedic injury) Laceration repair record only if sutured/stapled Nasogastric decompression record if within initial 24 hours of presentation Other (free text) Free text entry for number of consecutive days patient hospitalized at index admission (Day of admission = hospital day #0. Include any portion of a day that patient was in the hospital) LOS = Length of Stay. Recorded in days. Free text entry of number of days patient required ICU admission (ICU = Intensive Care Unit, LOS = Length of Stay). Day of admission = hospital day #0. Include any portion of a day that patient was in the ICU. Recorded in days. Number of separate units of packed red blood cells transfused in the first 24 hours after presentation
7 Ventilator Days Free text entry of the number of days the patient was on mechanical ventilation. Include any portion of a day that patient was ventilated. Recorded in days. Discharge data: Discharge to AMA Select patient s discharge destination: Home Self Care Home with Services Rehab Skilled Nursing Facility Long-term Care Psychiatric facility Hospice Morgue Correctional Facility Other Did the patient leave the hospital against medical advice? Yes/No Complications: Hospital Mortality Complications during admission Death during index hospitalization (yes or no) Recorded for all of the following: Sepsis Septic shock Acute renal injury Deep vein thrombosis Stroke Pulmonary embolism Myocardial infarction Cardiac arrest Central line-associated blood stream infection (CLABSI) Acute respiratory distress syndrome Post-operative hemorrhage Mechanical wound failure Ileus or other post-operative gastrointestinal complication Wound infection o Superficial o Deep Pneumonia (includes ventilator associated)
8 Readmission and Follow-up: Follow-up appointment completed Readmit Readmitdays Urinary tract infection Unplanned ICU admission Unplanned re-operation Unplanned intubation Other Was this patient seen in follow-up in an outpatient clinic setting with surgical team/primary care provider or documented follow-up (phone call, letter, etc) within 90 days of discharge date? (Yes, No, NR = Not Recorded) Patient readmitted for similar problem or complication from index hospitalization within 90 days of discharge. (Yes, No, NR = Not Recorded) Record number of days since discharge to first readmission. Round to nearest whole day. Site Information (only record once per site): Level of Trauma Center ACS admissions Record Level 1-4. If not designated as a trauma center, enter N/A. Record the number of acute care surgery admissions in the calendar year preceding the current year of the study
9 EAST Multi-Center Study Data Collection Tool Outcomes after acute care surgery and trauma care in incarcerated individuals: a prospective observational trial Enrolling Center: Case Number: Demographics: Age Sex: Race: Height (cm): Weight (kg): Primary payor: Comorbidities (check all that apply): Obesity Hypertension Diabetes mellitus Drug use disorder (including alcoholism) Mental health condition COPD CHF Dementia Anticoagulant use HIV Hepatitis C History of tobacco use Cancer: Type: Other: Pre-hospital Information: Location prior to presentation (circle): Prison Jail Outside ED Outside inpatient hospital Other: Duration of symptoms prior to arrival (circle): <12 hours hours >24 hours Unknown Has patient presented for evaluation for same injury or same problem: Yes No NR Incarceration Information: State of incarceration: Location of incarceration Prior to Arrival (circle): Prison Jail Unspecified Location of incarceration at Discharge (circle): Prison Jail Unspecified Diagnoses Was the patient admitted for trauma? (circle) Yes No Unknown Injury Information (if applicable):
10 ISS ED GCS: AIS: Head Spine Chest Abdomen Extremity Mechanism of Injury (check one): Fall MVC Pedestrian vs GSW Machine injury Assault Weapon: Hand/foot Blunt object Other Other: Intent of Injury (check if applicable): Intentional If yes: Self-harm Not self-harm Unintentional If yes: Occupational injury Not occupational injury Unspecified Admission: Admitting Service (check one): Trauma Orthopedic Surgery Neurosurgery Cardiothoracic Surgery General Surgery (non-trauma) Post ED Disposition (check one): Floor ICU Other - Consulting Service(s) (check all consulted): Trauma Orthopedic Surgery Neurosurgery Cardiothoracic Surgery General Surgery (non-trauma) Medicine ENT Plastic Surgery Other Step-down unit Discharge Medicine ENT Plastic Surgery Psychiatry Other Trauma Diagnoses (see appendix): Acute Surgical Diagnoses(see appendix):
11 Procedures: Need for operation (circle): Yes No NR Time to first operation: hours (Use decimals if needed) Number of Operations: CPT Procedure 1: CPT Procedure 3: CPT Procedure 2: CPT Procedure 4: Time to fixation (ortho injuries only): hours Other interventions (check all performed): Chest tube insertion Indication: Pneumothorax Hemothorax Other: Central line insertion Tracheostomy Traction Casting Laceration repair (with suture or staples only) Nasogastric decompression (in first 24 hours) Other: Admission Information: Hospital LOS: days ICU LOS: days Discharge Information: Discharged to: Home self-care Home with services Rehab Skilled Nursing Facility Long-term care Ventilator days: days Transfusion: /units prbcs in first 24 hours of admission Psychiatric facility Hospice Morgue Correctional Facility Other: Did the patient leave AMA (circle): Yes No Complications:
12 Did patient die during hospital stay: Yes No Complications during admission (check all that apply): Sepsis Wound infection Septic shock superficial Acute renal injury deep Deep vein thrombosis Pneumonia (including ventilator Stroke associated) Pulmonary embolism Urinary tract infection Myocardial infarction Unplanned ICU admission Cardiac arrest Unplanned reoperation Central line-associated blood stream Unplanned intubation infection Other: Acute respiratory distress syndrome Other: Post-operative hemorrhage Other: Mechanical wound failure Ileus or other GI complication Readmission and Follow-up: Readmit within 90 days: Yes No NR Number of days from discharge to readmission: days Follow-up appointment completed within 90 days: Yes No NR With (circle): Primary care Surgical Team
Welcome and Instructions
Welcome and Instructions For audio, join by telephone at 877-594-8353, participant code 56350822# Your line is OPEN. Please do not use the hold feature on your phone but do mute your line by dialing *6.
More informationDEPARTMENT OF SURGERY DIVISION OF ACUTE CARE SURGERY ACUTE CARE SURGERY ROTATION (SA1 & SA2)
DEPARTMENT OF SURGERY DIVISION OF ACUTE CARE SURGERY ACUTE CARE SURGERY ROTATION (SA1 & SA2) University Hospital C.S. Mott Children s Hospital Von Voigtlander Women s Hospital Cardiovascular Center House
More informationCMS Quality Program- Outcome Measures. Kathy Wonderly RN, MSEd, CPHQ Consultant Developed: December 2015 Revised: January 2018
CMS Quality Program- Outcome Measures Kathy Wonderly RN, MSEd, CPHQ Consultant Developed: December 2015 Revised: January 2018 Philosophy The Centers for Medicare and Medicaid Services (CMS) is changing
More information*Your Name *Nursing Facility. radiation therapy. SECTION 2: Acute Change in Condition and Factors that Contributed to the Transfer
Gaining information about resident transfers is an important goal of the OPTIMISTC project. CMS also requires us to report these data. This form is where data relating to long stay transfers are to be
More informationEssentials for Clinical Documentation Integrity 2017
Essentials for Clinical Documentation Integrity 2017 Prepared and Published By: MedLearn Publishing A Division of Panacea Healthcare Solutions, Inc. 287 East Sixth Street, Suite 400 St. Paul, MN 55101
More informationROTATION: TRAUMA AND CRITICAL CARE (L AND A SURGERY)
July 2011 ROTATION: TRAUMA AND CRITICAL CARE (L AND A SURGERY) ROTATION DIRECTOR: Areti Tillou, M.D. CHIEF OF TRAUMA SURGERY: Henry G. Cryer, M.D. SITE: RRUMC GOALS AND OBJECTIVES: To provide trainees
More informationThe Impact of Healthcare-associated Infections in Pennsylvania 2010
The Impact Healthcare-associated Infections in Pennsylvania 2010 Pennsylvania Health Care Cost Containment Council February 2012 About PHC4 The Pennsylvania Health Care Cost Containment Council (PHC4)
More informationTammy Morgan Terri Swiencicki Michelle Pomphrey. Trauma Quality Improvement Program (TQIP) Annual Scientific Meeting and Training 2012
TQIP Abstractor Workshop Tammy Morgan Terri Swiencicki Michelle Pomphrey Trauma Quality Improvement Program (TQIP) Annual Scientific Meeting and Training 2012 You are important to TQIP, and we want to
More informationThe Ohio State University Department of Orthopaedics. Residency Curriculum. PGY1 Rotations
The Ohio State University Department of Orthopaedics Residency Curriculum PGY1 Rotations Goals and Objectives Anesthesiology Rotation PGY1 Level I. Core Competency Areas By the end of the PGY1 rotation
More informationSurgical Residency Curriculum
Community Memorial Hospital Surgical Residency Curriculum Program Director: G. W. Iwasiuk MD FACS 2016 Educational Goals & Objectives Surgeons provide continuing care for patients with a myriad of surgical
More informationEMERGENCY MEDICINE CLINICAL ROTATION COMPETENCY BASED CURRICULUM
CLINICAL ROTATION COMPETENCY BASED CURRICULUM EMERGENCY MEDICINE During the third year of the curriculum, students expand their knowledge of emergent conditions and gain the ability to apply the knowledge
More informationReducing Readmissions: Potential Measurements
Reducing Readmissions: Potential Measurements Avoid Readmissions Through Collaboration October 27, 2010 Denise Remus, PhD, RN Chief Quality Officer BayCare Health System Overview Why Focus on Readmissions?
More informationMinnesota Statewide Quality Reporting and Measurement System: Appendices to Minnesota Administrative Rules, Chapter 4654
This document is made available electronically by the Minnesota Legislative Reference Library as part of an ongoing digital archiving project. http://www.leg.state.mn.us/lrl/lrl.asp Minnesota Statewide
More informationUsing the Trauma Quality Improvement Program (TQIP) Metrics Data to Change Clinical Practice Abigail R. Blackmore, MSN, RN Pamela W.
Using the Trauma Quality Improvement Program (TQIP) Metrics Data to Change Clinical Practice Abigail R. Blackmore, MSN, RN Pamela W. Bourg, PhD, RN, TCRN, FAEN Learning Objectives Explain the importance
More informationPenn State Milton S. Hershey Medical Center. Division of Trauma, Acute Care & Critical Care Surgery
Penn State Milton S. Hershey Medical Center Division of Trauma, Acute Care & Critical Care Surgery Residency-Trauma Curriculum The Medical Director for the Penn State Shock Trauma Center is Dr. Heidi Frankel.
More informationTITLE/DESCRIPTION: Admission and Discharge Criteria for Telemetry
TITLE/DESCRIPTION: Admission and Discharge Criteria for Telemetry DEPARTMENT: PERSONNEL: Telemetry Telemetry Personnel EFFECTIVE DATE: 6/86 REVISED: 02/00, 4/10, 12/14 Admission Procedure: 1. The admitting
More informationTrauma. Level 2. This resident can lead a to recognize common. This resident can. accurately diagnose. team that cares for traumatic conditions and
Page 1 of 7 Trauma Subject Name Status Employer Program Rotation Evaluation Dates Evaluated by: Evaluator Name Status Employer Program 1 (Trauma) Patient Care: Ward Care This resident is not able lead
More informationSANTA ROSA MEMORIAL HOSPITAL AND AFFILIATED ENTITIES ONGOING PROFESSIONAL PRACTICE EVALUATION POLICY (OPPE)
SANTA ROSA MEMORIAL HOSPITAL AND AFFILIATED ENTITIES ONGOING PROFESSIONAL PRACTICE EVALUATION POLICY (OPPE) Discussion Draft August 6, 2017 Horty, Springer & Mattern, P.C. 250979.8 ONGOING PROFESSIONAL
More informationGender. Age DEMOGRAPHICS POINTS OF DISTINCTION COMISSION FOR ACCREDITATION OF REHABILITATION FACILITIES STATE OF FLORIDA BRAIN AND SPINAL CORD PROGRAM
POINTS OF DISTINCTION 89-bed Acute Adult Inpatient Rehabilitation Unit, All private rooms 4 th largest Rehabilitation provider in the state of Florida Admitted 2157 patients from April 2017 through March
More informationObservation Unit. Romil Chadha
Observation Unit Romil Chadha Observation vs Inpatient Whenever in doubt please call 3-3070 to get assistance from Utilization Review (UR) Randy A. Rosen, MD, reviews cases and usually emails about patients
More informationSPECIALTY SPECIFIC OBJECTIVES
Family Medicine Residency Internal Medicine In-house II Rotation Rotation Goal Admission, evaluation, treatment and appropriate specialty consultation of adult hospitalized patients from either the ER,
More informationTransitions Through the Care Continuum: Discussions on Barriers to Patient Care, Communications, and Advocacy
Transitions Through the Care Continuum: Discussions on Barriers to Patient Care, Communications, and Advocacy Scott Matthew Bolhack, MD, MBA, CMD, CWS, FACP, FAAP April 29, 2017 Disclosure Slide I have
More informationPediatric Surgery Curriculum Clinical Base Year
Pediatric Surgery Curriculum Clinical Base Year Collaborating Faculty: Cindi Graves, MD Residency Program Director Department of Surgery Purpose and Educational Value The purpose of the Pediatric Surgery
More informationInpatient Rehabilitation Program Information
Inpatient Rehabilitation Program Information The Inpatient Rehabilitation Program at TIRR Memorial Hermann The Woodlands has a team of physicians, therapists, nurses, a case manager, neuropsychologist,
More informationBeth Israel Deaconess Medical Center Department of Anesthesia, Critical Care, and Pain Medicine Rotation: Post Anesthesia Care Unit (CA-1, CA-2, CA-3)
Beth Israel Deaconess Medical Center Department of Anesthesia, Critical Care, and Pain Medicine Rotation: Post Anesthesia Care Unit (CA-1, CA-2, CA-3) Goals GOALS AND OBJECTIVES To analyze and interpret
More informationAHU-FON-NUR- CS -ACD 15 Al Hussein Bin Talal University Princess Aisha Bint Al-Hussein College of Nursing and Health Sciences Course Syllabus
Department: Nursing Course Title: Critical Care Nursing (theory) Credit Hours: 3 Hours Course Number: 0901421 co-requisites: Course Year Level: Faculty Member Day- Time: E-mail: Office Hours: Course Website:
More informationTQIP and Risk Adjusted Benchmarking
TQIP and Risk Adjusted Benchmarking Melanie Neal, MS Manager Trauma Quality Improvement Program TQIP Participation Adult Only Centers 278 Peds Only Centers 27 Combined Centers 46 Total 351 What s new TQIP
More informationBalancing State, Federal and Internal Bundle Payment Initiatives
Balancing State, Federal and Internal Bundle Payment Initiatives Vanderbilt University Medical Center Brittany Cunningham, MSN, RN, CSSBB Director, Episodes of Care Key Take Aways What are the different
More informationHOSPITAL QUALITY MEASURES. Overview of QM s
HOSPITAL QUALITY MEASURES Overview of QM s QUALITY MEASURES FOR HOSPITALS The overall rating defined by Hospital Compare summarizes up to 57 quality measures reflecting common conditions that hospitals
More informationClinical Documentation: Beyond The Financials Cheryll A. Rogers, RHIA, CDIP, CCDS, CCS Senior Inpatient Consultant 3M HIS Consulting Services
Clinical Documentation: Beyond The Financials Cheryll A. Rogers, RHIA, CDIP, CCDS, CCS Senior Inpatient Consultant 3M HIS Consulting Services Clinical Documentation: Beyond The Financials Key Points of
More informationHospice Codes. Table 1 ALS Diagnosis. Table 2 Alzheimer s Disease and Related Disorder Diagnoses. Table 3 Heart Disease Diagnoses
I N D I A N A H E A L T H C O V E R A G E P R O G R A M S P R O V I D E R C O D E S E T S Hospice Codes Table 1 ALS Diagnosis Table 2 Alzheimer s Disease and Related Disorder Diagnoses Table 3 Heart Disease
More informationRisk Factor Analysis for Postoperative Unplanned Intubation and Ventilator Dependence
Risk Factor Analysis for Postoperative Unplanned Intubation and Ventilator Dependence Adam P. Johnson MD, MPH, Anisha Kshetrapal MD, Harold Hsu MD, Randi Altmark RN, BSN, Herbert E Cohn MD, FACS, Scott
More informationFebruary 2009 [KU 1018] Sub. Code: 4717
February 2009 [KU 1018] Sub. Code: 4717 Second Year Paper II MEDICAL SURGICAL NURSING - I Answer ALL questions. I. Essays: (2x15=30) 1. Mr.Mani 64 yrs old man is admitted with the diagnosis of Benign Prostatic
More informationEMERGENCY MEDICINE ROTATION SYLLABUS
EMERGENCY MEDICINE ROTATION SYLLABUS Level of Training PGY1, PGY2 Length of Training 4 weeks Preceptors /Attendings Name(s) and Titles Bansidas M. Agravat, MD Sarmed Ashoo, MD Murray Baker, MD Stephen
More informationNURSING COMPUTER SOFTWARE. Level 1- Semester 2. Medical Surgical Nursing/ Clinical Lab
NURSING COMPUTER SOFTWARE Level 1- Semester 2 Nur 1210/ 1210L Medical Surgical Nursing/ Clinical Lab RECOMMENDED FOR ALL COURSES: Successful Test- taking Tips for Windows: (Copyright 1998) Test-Taking
More informationFamily Medicine Residency Surgery Rotation
Family Medicine Residency Surgery Rotation Rotation Goal The overall goal for the educational experience provided in the areas of general surgery, trauma surgery, office orthopedic surgery and sports medicine,
More informationO U T C O M E. record-based. measures HOSPITAL RE-ADMISSION RATES: APPROACH TO DIAGNOSIS-BASED MEASURES FULL REPORT
HOSPITAL RE-ADMISSION RATES: APPROACH TO DIAGNOSIS-BASED MEASURES FULL REPORT record-based O U Michael Goldacre, David Yeates, Susan Flynn and Alastair Mason National Centre for Health Outcomes Development
More informationFY2013-FY2014 CHANGES TO ICD-9-CM CODING HANDBOOK WITH ANSWERS
FY2013-FY2014 CHANGES TO ICD-9-CM CODING HANDBOOK WITH ANSWERS Narrative changes appear in bold italicized text; deletions show as strike-through text. Revised 4/10/14 Page FY2012 Text Number 39 Because
More informationSupervision of Residents/Chain of Command
Supervision of Residents/Chain of Command Creighton University Department of Surgery Residency Training Program Chain of command for Surgery residents at CUMC PGY1: The intern on call covers the two general
More informationHospital Inpatient Quality Reporting (IQR) Program Measures (Calendar Year 2012 Discharges - Revised)
The purpose of this document is to provide a reference guide on submission and Hospital details for Quality Improvement Organizations (QIOs) and hospitals for the Hospital Inpatient Quality Reporting (IQR)
More informationDuring the hospital medicine rotation, residents will focus on the following procedures as permitted by case mix:
Educational Goals & Objectives The Inpatient Family Medicine rotation will provide the resident with an opportunity to evaluate and manage patients with common acute medical conditions. Training will focus
More informationTrauma Rotation UMASS Memorial University Campus
Trauma Rotation UMASS Memorial University Campus * The following objectives include goals and achievements set forth for successful completion in the acute surgery & trauma rotation such that residents
More informationEmergency Medicine Syllabus
Emergency Medicine Syllabus Table of Contents Introduction COURSE GOALS and OBJECTIVES Windsor University Clinical PROGRAM s TOPICS 1) Focused Emergency Topics 2) Preceptor s Teaching Schedule Template
More informationIowa Healthcare Collaborative - HEN 2.0 Measures
Iowa Healthcare Collaborative - HEN 2.0 Measures Yellow Pink Purple Green Blue Legend Readmissions and Care Transitions Healthcare-associated Infections Hospital Acquired Conditions Safety Across the Board
More informationLearning Objectives. Denver Health Medical Center. Complex Coding Scenarios and Resolution
Complex Coding Scenarios and Resolution Eric Ryland, MS, RHIA, CCDS, CHDA, CCS, CPC Manager of Coding Denver Health Medical Center Denver, Colo. 2 Learning Objectives Denver Health Medical Center Evaluate
More informationN: Emergency Nursing. Alberta Licensed Practical Nurses Competency Profile 135
N: Emergency Nursing Alberta Licensed Practical Nurses Competency Profile 135 Competency: N-1 Multi-Systems Assessment N-1-1 N-1-2 N-1-3 N-1-4 Demonstrate knowledge and ability to apply critical thinking
More information@ncepod #tracheostomy
@ncepod #tracheostomy 1 Introduction Tracheostomy: Remedy upper airway obstruction Avoid complications of prolonged intubation Protection & maintenance of airway The number of temporary tracheostomies
More informationAnalysis of Final Rule for FY 2009 Revisions to the Medicare Hospital Inpatient Prospective Payment System
Analysis of Final Rule for FY 2009 Revisions to the Medicare Hospital Inpatient Prospective Payment System The final rule regarding fiscal year (FY) 2009 revisions to the Medicare hospital inpatient prospective
More informationWhy Shepherd? Shepherd Center Patients. Here s How We Measure Up: Shepherd Patient Population
Center Patients Total Patients ABI Patients SCI Patients Other Patients Center specializes in medical treatment, research and rehabilitation for people with spinal cord and brain injury. In CY, had 911
More informationDUKE INTERNAL MEDICINE RESIDENCY PROGRAM. GASTROENTEROLOGY SUBSPECIALTY CONSULTS (ELECTIVE) ROTATION DESCRIPTION Biliary, General GI and Hepatology
Department of Medicine Internal Medicine Residency Program DUKE INTERNAL MEDICINE RESIDENCY PROGRAM GASTROENTEROLOGY SUBSPECIALTY CONSULTS (ELECTIVE) ROTATION DESCRIPTION Biliary, General GI and Hepatology
More informationReport of the Incidence and Prevalence of Diseases and other Health Related Issues in Saudi Arabia
Report of the Incidence and Prevalence of Diseases and other Health Related Issues in Saudi Arabia A study for the SMLE Blueprint Project Heba AlManea Assessment Executive Specialist, SCFHS Dr Abdulmohsen
More informationAugust 1, 2012 (202) CMS makes changes to improve quality of care during hospital inpatient stays
DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Room 352-G 200 Independence Avenue, SW Washington, DC 20201 FACT SHEET FOR IMMEDIATE RELEASE Contact: CMS Media Relations
More informationNursing Unit Descriptions UCHealth Memorial Hospital Central
Nursing Unit Descriptions UCHealth Memorial Hospital Central ACUTE CARE SERVICES Neuroscience 5C Neuroscience is a 24-bed unit with all private rooms for our patients. The department specializes in acute
More informationPatient Identifiers: Facial Recognition Patient Address DOB (month/day year) / / UHHC. Month Day Year / / Month Day Year
Transfer (M0010) CMS Certification Number: 367549 (M0014) Branch State: OH (M0016) Branch ID Number: N/A Patient Identifiers: Facial Recognition Patient Address DOB (month/day year) / / UHHC (M0020) Patient
More informationABOUT THE CONE HEALTH NETWORK OF SERVICES
THE MOSES H. CONE MEMORIAL HOSPITAL (536 beds) Critical Care Services All system ICU patients are monitored with the help an electronic ICU monitoring system (VISICU ). Emergency Services Medical Intensive
More informationDischarge checklist and follow-up phone calls: the foundation to an effective discharge process
Discharge checklist and follow-up phone calls: the foundation to an effective discharge process Shari Aman, BSN, RN, MBA, CPHQ Denise Andrews, MBA Stephanie Storie, BSN, RN, CMSRN Deb Nation, RN, CMSRN
More informationJuly 2018 TRAUMA REGISTRY UPDATE. Excellence, Innovation, Integrity & Teamwork
Trauma Program Registrars, Trauma Program Managers/Coordinators & Trauma Performance Improvement Coordinators: Please review the below information for multiple trauma registry-related updates. If you have
More informationClinical Privileges Profile Family Medicine. Kettering Medical Center System
Clinical Privileges Profile Kettering Medical Center Sycamore Medical Center Kettering Medical Center System Applicant: Check off the Requested box for each privilege requested. Applicants have the burden
More informationStudy Title: Optimal resuscitation in pediatric trauma an EAST multicenter study
Study Title: Optimal resuscitation in pediatric trauma an EAST multicenter study PI/senior researcher: Richard Falcone Jr. MD, MPH Co-primary investigator: Stephanie Polites MD, MPH; Juan Gurria MD My
More informationNURSING COMPUTER SOFTWARE. Level 2- Semester 4. Advanced Medical Surgical Nursing/ Clinical Lab
NURSING COMPUTER SOFTWARE Level 2- Semester 4 Nur 1210/ 1210L Advanced Medical Surgical Nursing/ Clinical Lab RECOMMENDED FOR ALL COURSES: Successful Test- taking Tips for Windows: (Copyright 1998) Test-Taking
More informationPatient Registration. City, State & Zip Code Date of Birth Age. Occupation: Family Physician: Married Single Other Spouse's Name
*SHAREDID-42* Date of Birth: Page 1 of 2 Patient Registration Account # Patient Name Home Telephone # Work Telephone # Social Security Number Cell Telephone # Address Patient Sex City, State & Zip Code
More informationEvidence for Accreditation in Bariatric Surgery Hospitals
Evidence for Accreditation in Bariatric Surgery Hospitals John Morton, MD, MPH, FASMBS, FACS Chief, Bariatric and Minimally Invasive Surgery Stanford School of Medicine President,American Society for Metabolic
More informationPOLICY AND PROCEDURE MANUAL
Policy Title: Authorization for Observation vs. Inpatient Admission for Contracted Hospitals Primary Department: Affiliated Department(s): N/A Last Revision Date: 08/20/2015 Revision Dates: 12/16/2011;
More informationDisclosure of Proprietary Interest
HomeTown Health HCCS Hospital Consortium Project: Track 3- Clinical Documentation: Strategies for Sharpening Focus Jenan Custer RHIT, CCS, CPC, CDIP AHIMA Approved ICD-10-CM/PCS Trainer Director of Coding
More informationSee the Time chapter for complete instructions on how to code using time as the controlling factor when selecting an E/M code.
2015 EM Survival Guides Chapter 4: Initial Hospital Care (99221-99223) You should select the appropriate-level initial hospital care code (99221-99223) using the key E/M criteria of history, examination
More informationAl al-bayt University. Nursing Faculty. Adult Health Nursing-1 ( ) Course Syllabus
Al al-bayt University Nursing Faculty Adult Health Nursing-1 (1001221) Course Syllabus 2009/2010 1 Course Title: Adult Health Nursing-1 (1001221) Credit Hours: 3 Hours. Pre-requisite: (1001171) Date: first
More informationSupplementary Online Content
Supplementary Online Content Kaukonen KM, Bailey M, Suzuki S, Pilcher D, Bellomo R. Mortality related to severe sepsis and septic shock among critically ill patients in Australia and New Zealand, 2000-2012.
More informationNASHP s 30 th Annual State Health Policy Conference. Timeline of Tennessee Health Care Innovation Initiative
STATE OF TENNESSEE NASHP s 30 th Annual State Health Policy Conference 10/25/2017 Timeline of Tennessee Health Care Innovation Initiative 2012 2013 2014 2015 2016 2017 1210 Stakeholder Meetings 16 Partnerships
More informationThe 2013 Boston Marathon Bombings
The 2013 Boston Marathon Bombings Lessons Learned from a Resource-Rich Urban Battlefield Presented at the 41 st Convention of the American Society of Plastic Surgical Nurses Boston, Massachusetts October
More informationHealth Economics Program
Health Economics Program Issue Brief 2006-02 February 2006 Health Conditions Associated With Minnesotans Hospital Use Health care spending by Minnesota residents accounts for approximately 12% of the state
More informationBundled Payment Primer
Bundled Payment Primer CMS Opened Application February 14, 2014 Why this matters to you! Bundling is a New Business Model Bundling is a focused opportunity to manage risk and achieve gain Control of a
More informationImpacting Quality Initiatives through Documentation Improvement. Fran Jurcak, MSN, RN, CCDS Vice President of Clinical Innovation Iodine Software
Impacting Quality Initiatives through Documentation Improvement Fran Jurcak, MSN, RN, CCDS Vice President of Clinical Innovation Iodine Software Objectives The learner will be able to: Articulate the goals
More informationTRAUMA AND EMERGENCY SURGERY CORE OBJECTIVES: PGY 4
TRAUMA AND EMERGENCY SURGERY CORE OBJECTIVES: PGY 4 GOALS Through rotation on the trauma and emergency surgery service, residents shall attain the following goals: I. Patient Care A. Trauma Resuscitations
More informationUsing Clinical Criteria for Evaluating Short Stays and Beyond. Georgeann Edford, RN, MBA, CCS-P. The Clinical Face of Medical Necessity
Using Clinical Criteria for Evaluating Short Stays and Beyond Georgeann Edford, RN, MBA, CCS-P The Clinical Face of Medical Necessity 1 The Documentation Faces of Medical Necessity ç3 Setting the Stage
More informationNational Patient Safety Goals & Quality Measures CY 2017
National Patient Safety Goals & Quality Measures CY 2017 General Clinical Orientation 2017 January National Patient Safety Goals 1. Identify Patients Correctly 2. Improve Staff Communication 3. Use Medications
More informationOverview of Final Rule for FY 2011 Revisions to the Medicare Hospital Inpatient Prospective Payment System
Overview of Final Rule for FY 2011 Revisions to the Medicare Hospital Inpatient Prospective Payment System The final rule regarding fiscal year (FY) 2011 revisions to the Medicare hospital inpatient prospective
More informationTESTING Computer Adaptive Testing (CAT)...1 Test Taking Strategies... 2
Table OF CONTENTS TESTING Computer Adaptive Testing (CAT)...1 Test Taking Strategies... 2 CONCEPTS OF NURSING PRACTICE Maslow s Hierarchy of Basic Human Needs...3 Steps in the Nursing Process... 4 The
More informationPatient Experience of Care Survey Results Hospital Consumer Assessment of Healthcare Providers and Systems (Inpatient)
Patient Experience of Care Survey Results Hospital Consumer Assessment of Healthcare Providers and Systems (Inpatient) HCAHPS QUESTION DESCRIPTION (April 2016 - March 2017) Patients who reported that their
More informationEMERGENCY MEDICINE. Clerkship Director Emergency Medicine TEL: Des Moines, Iowa TEL: FAX:
EMERGENCY MEDICINE Thomas Benzoni, DO, FACEP Office for Clinical Affairs Clerkship Director Emergency Medicine 3200 Grand Avenue TEL: 515-271-7816 Des Moines, Iowa 50312 TEL: 515-271-1629 FAX: 515-271-1727
More information3M Potentially Preventable Complications (PPCs) Version 31.0 (effective 10/01/2013) Methodology Overview
3M Potentially Preventable Complications (PPCs) Version 31.0 (effective 10/01/2013) Methodology Overview 3 Copyright 2013 2008, 3M. All rights reserved. This product contains material and information that
More informationDiagnostics for Patient Safety and Quality of Care. Vulnerable System Syndrome
Diagnostics for Patient Safety and Quality of Care Carol Haraden, PhD September 2012 This presenter has nothing to disclose. Vulnerable System Syndrome Three core pathologies: - Blame - Denial - And the
More informationSaint Agnes Hospital. Pharmacist utilization of the LACE tool to prevent hospital readmissions. Program/Project Description, including Goals:
Saint Agnes Hospital Pharmacist utilization of the LACE tool to prevent hospital readmissions Program/Project Description, including Goals: Safe transitions of care have always been a frontline patient
More informationInnovating Predictive Analytics Strengthening Data and Transfer Information at Point of Care to Improve Care Coordination
Innovating Predictive Analytics Strengthening Data and Transfer Information at Point of Care to Improve Care Coordination November 15, 2017 RRHA Healthcare Innovations Conference Agenda Arnot Health Overview
More information2006 Clinical Coding Workout 5/3/2006 MISSING QUESTIONS Chapter 5, Intermediate Ambulatory Page 1
Chapter 5, Intermediate Ambulatory Page 1 CPT Modifier Use 5.81. Dr. Raddy, staff radiologist, interprets a chest x-ray that was obtained in the hospital Radiology Department. Dr. Raddy is contracted with
More informationAppendix: Assessments from Coping with Cancer
Appendix: Assessments from Coping with Cancer Primary Independent Variable of Interest (assessed at baseline with medical chart review and confirmed with clinician) 1. What treatments is the patient currently
More informationCommunity Performance Report
: Wenatchee Current Year: Q1 217 through Q4 217 Qualis Health Communities for Safer Transitions of Care Performance Report : Wenatchee Includes Data Through: Q4 217 Report Created: May 3, 218 Purpose of
More informationSTATISTICAL BRIEF #9. Hospitalizations among Males, Highlights. Introduction. Findings. June 2006
HEALTHCARE COST AND UTILIZATION PROJECT STATISTICAL BRIEF #9 Agency for Healthcare Research and Quality June 2006 Hospitalizations among Males, 2003 C. Allison Russo, M.P.H. and Anne Elixhauser, Ph.D.
More informationICU Nurse, 10 years experience. Major NHS hospital north of London
NAME AND CONTACT INFO WITHHELD CONTACT PASSPORT USA FOR FURTHER DETAILS. 855.531.8555 ICU Nurse, 10 years experience. Major NHS hospital north of London DATE OF BIRTH: March 1, 1977 NATIONALITY: Filipino.
More informationQuestions. Background to the ICNARC Case Mix Programme
Number of admissions, unit length of stay and days of mechanical ventilation for admissions with blunt chest trauma to critical care in England, Wales and Northern Ireland Questions What were the number,
More informationTake Charge of Your CE
Take Charge of Your CE And Build Your Lifelong Learning Record in Healthcare Today! The Nurses Network is a leading content publisher focused on building courseware BY Nurses FOR Nurses, offering both
More informationINTERQUAL ACUTE CRITERIA REVIEW PROCESS
REVIEW RP-1 RP-2 REVIEW The InterQual Acute Criteria provide support for determining the appropriateness of admission, continued stay and discharge. The Acute Criteria address the observation, critical,
More informationTo teach residents the fundamentals of patient triage and prioritization of medical care.
EMERGENCY MEDICINE Overview Most of the Emergency Medicine Experience occurs predominantly during PGY-1 or PGY-2 Emergency Blocks. In addition, all inpatient rotations provide residents varying degrees
More informationGeneral information. Hospital type : Acute Care Hospitals. Provides emergency services : Yes. electronically between visits : Yes
General information 80 JESSE HILL, JR DRIVE SE ATLANTA, GA 30303 (404) 616 45 Overall rating : 1 out of 5 stars Learn more about the overall ratings General information Hospital type : Acute Care Hospitals
More informationMinnesota Statewide Quality Reporting and Measurement System: APPENDICES TO MINNESOTA ADMINISTRATIVE RULES, CHAPTER 4654
Minnesota Statewide Quality Reporting and Measurement System: APPENDICES TO MINNESOTA ADMINISTRATIVE RULES, CHAPTER 4654 DECEMBER 2017 APPENDICES TO MINNESOTA ADMINISTRATIVE RULES, CHAPTER 4654 Minnesota
More informationDelineation of Privileges and Credentialing for Critical Care Procedures
Delineation of Privileges and Credentialing for Critical Care Procedures Marialice Gulledge, DNP, ANP-BC Chief, Nurse Practitioner Trauma and Acute Care Surgery Disclosure Faculty/presenters/authors/content
More informationAdditional Considerations for SQRMS 2018 Measure Recommendations
Additional Considerations for SQRMS 2018 Measure Recommendations HCAHPS The Hospital Consumer Assessments of Healthcare Providers and Systems (HCAHPS) is a requirement of MBQIP for CAHs and therefore a
More informationAddressing and clarifying 2017 Guideline recommendations
Addressing and clarifying 2017 Guideline recommendations WHITE PAPER z FEATURES Supportive documentation..2 Tipping the scales... 3 Reminders... 3 Additional changes... 4 PCS concerns... 5 Sepsis... 7
More informationNORTH DAKOTA LEVEL OF CARE FORM INSTRUCTIONS TO BE USED WITH LOC FORM ND
For this section, select which type of LOC screen is to be reviewed Requested Screen Type NORTH DAKOTA LEVEL OF CARE FORM INSTRUCTIONS Nursing Facility Swingbed CMFN PACE MFP Provisional MFP Final Tech.
More information1. Recommended Nurse Sensitive Outcome: Adult inpatients who reported how often their pain was controlled.
Testimony of Judith Shindul-Rothschild, Ph.D., RNPC Associate Professor William F. Connell School of Nursing, Boston College ICU Nurse Staffing Regulations October 29, 2014 Good morning members of the
More informationLOYOLA UNIVERSITY MEDICAL CENTER RESIDENCY PROGRAM IN GENERAL SURGERY CLINICAL ROTATION DESCRIPTION. Hines VA Hospital General Surgery
LOYOLA UNIVERSITY MEDICAL CENTER RESIDENCY PROGRAM IN GENERAL SURGERY CLINICAL ROTATION DESCRIPTION Hines VA Hospital General Surgery RESIDENT COMPLEMENT: ROTATION DURATION: PG1, PGY 3 & PG5 PG1 1 month
More information