Alex's ER Visit/Consult/Procedure

TIMESTAMPS

[Use the following format for this section: ASSESSMENT: XXXXh REASSESSMENT: XXXXh CONSULTATION: XXXXh] [Omit any of the headings above that are not mentioned in the transcript.] [Use military time in Pacific Standard Time, as dictated by me. I will say something like "time of assessment 2300h", and this would be transcribed as: "ASSESSMENT: 2300h". If no time is mentioned, use the time that recording for this patient began. If I dictate an assessment time afterwards, update accordingly.] [Only include a reassessment time above if I mention the keyword "Reassessment", ie "patient is reassessed at 1400h" or "reassessment note, time 1500h". else leave this section EMPTY.] [If a reassessment note is dictated without a time mentioned, make it 2 hours and 1 minute after the initial assessment time for this note.] [If a resuscitation is dictated, include the start and end time in the same style and format as the other times in this note, ie: RESUSCITATION: XXXXh-YYYYh] [I state that I consulted a specialist in real-time for advice and/or management, state the time in this format: "CONSULTATION: XXXXh"]

PROCEDURE

[List name of major procedures done by the ERP. No details required, just the name of the procedure, along with the MSP numeric billing code, a timestamp if provided, and the anesthetic level corresponding to the code from the information below, if available. Imaging tests and labs are not procedures. Items to exclude would be IV cannulation, swabs. ] [Use the following list for common ED procedures, starting with their numeric MSP billing code. GA refers to use of general anesthesia, such as procedural sedation: 06222 Reduce Phalanx Fracture 06223 Reduce Metacarpal Fracture 57771 Reduce Metatarsal phalangeal dislocation and cast without GA (single or multiple). 57772 Reduce Metatarsal Phalangeal Dislocation and Cast, with GA (single or multiple). 57792 Interphalangeal Dislocations +/- Fracture Closed reduction, with GA, Cast, Single or Multiple 57791 Interphalangeal Dislocations +/- Fracture Closed reduction, without GA, cast, single or multiple 57701 Fracture and/or Dislocation: Ankle Fracture: Intra-articular Tibial Metaphysial (PILON) Closed reduction, with GA, cast/traction 57711 Closed reduction ankle fracture, without GA, cast, single or multiple 57712 Closed reduction of Ankle Malleolar Fracture, with GA, application of cast 57711 Closed reduction of Ankle Malleolar Fracture, without GA, application of cast 57722 Closed reduction,of Hindfoot/midfoot/LisFranc’s dislocation +/- Fracture with GA, cast 57721 Closed reduction of Hindfoot/midfoot/lis franc’s dislocation +/- Fracture, without GA, cast 56751 Tibial Shaft Fracture Reduction – no General Anesthetic – Anesthetic Level 2 56752 Tibial Shaft Fracture Reduction – with General Anesthetic cast/traction – Anesthetic Level 2 56800 Manipulation of the Knee Under GA (An example would be a locked knee due to a meniscal tear, manipulated to allow movement while awaiting to see Ortho for investigation +/- repair) 55780 Femur Shaft Fracture Reduction – no GA with cast/traction- Anesthetic Level 2 55781 Femur Shaft Fracture Reduction – with GA, cast/traction Anesthetic Level 2 53761 Radius/Ulna Shaft Fracture Reduction – no GA with cast (operation only) Anes. Level 2 53762 Radius/Ulna Shaft Fracture Reduction – with GA- & cast Anes. Level 2 52721 Shoulder (Acute glenohumeral) Dislocation Reduction – operation only -no GA 52722 Shoulder (Acute glenohumeral) Dislocation Reduction – with GA 01861 Patellar Reduction – See Below 55712 Reduction of Traumatic Hip Dislocation– with GA 55711 Reduction of Traumatic hip dislocation, without GA 53751 Reduction of Elbow Joint Dislocation – no GA 53752 Closed reduction of elbow joint dislocation, with GA 53741 Closed reduction of a dislocated radial head/shaft, with GA, cast 01850 Clavicle – See Below 01851 Fibula – Shaft or Malleolus Not Requiring Reduction – See Below 54702 Fracture of distal radius +/- ulna +/- dislocation – reduction with GA, cast 54701 Fracture of distal radius +/- ulna +/- dislocation – reduction without GA, cast 13660 Metatarsal Bone – Closed Reduction – Operation Only 01850 Clavicle (ED only) 01851 Fibula (ED only) 01860 TMJ (ED) 01861 Patella (ED only) 01862 Toe Reduction (ED only) 32031 – Chest Tube Placement (closed drainage of chest) – Thoracostomy Closed drainage of chest– operation only ………………………………………………….$137.00 (4) This may be used when draining a pleural effusion/pneumothorax or a non-life threatening tube insertion. During resuscitation, please bill 001870/71 or 00081 (on-site on-duty or on-call call-in sites respectively) 07150 is restricted to Gen Sx & Resp Abdominal paracentesis 00760 S00760 – (abdominal paracentesis) – procedural fee .$25.79 …………….2 Tip: If you do need to send off fluid for diagnostics like cells, cytology, C& S etc then also bill the $76.01 07041: Aspiration of abdomen or chest 07041 -Aspiration: abdomen or chest Aspiration: abdomen or chest (operation only)……………………………………………..$ 76.01 This would include the aspiration of ascitic fluid for diagnostics. P04330: Word Catheter for Bartholin’s cyst P04330 I&D of Bartholin’s cyst with insertion of Word catheter (operation only) ………… 275.00 anesthetic Level2 Note: 07027 to be charged if Bartholin’s cyst/abscess is treated by Incision and Drainage (I&D) without insertion of a Word catheter. 06222 Reduce Phalanx Fracture 06223 Reduce Metacarpal Fracture 57771 Reduce Metatarsal phalangeal dislocation and cast without GA (single or multiple). 57772 Reduce Metatarsal Phalangeal Dislocation and Cast, with GA (single or multiple) 57712* Ankle Malleolar Fracture Closed reduction, with GA, application of cast 57792 Interphalangeal dislocations, Closed reduction +/- Fracture, with GA, cast, single or multiple 57791 Closed reduction Interphalangeal dislocations, without GA, cast, single or multiple 57711 Closed reduction of Ankle Malleolar Fracture, without GA, application of cast 01850 Clavicle Fracture 01851 Fibula – Shaft or Malleolus Not Requiring Reduction Radial Head Subluxation – Reduction 13660 Metatarsal Bone – Closed Reduction – Operation Only 06236 Metacarpophalangeal or interphalangeal joint: – closed reduction 51016 Short Arm Cast (by MD) 51019 Below Knee Cast (by MD) 51017 Long Arm Cast (by MD) 51021 Long Leg Cast (by MD) 57791 Interphalangeal Dislocations +/- Fracture Closed reduction, without GA, cast, single or multiple 57712 Closed reduction of Ankle Malleolar Fracture, with GA, application of cast 57722 Closed reduction,of Hindfoot/midfoot/LisFranc’s dislocation +/- Fracture with GA, cast 57721 Closed reduction of Hindfoot/midfoot/lis franc’s dislocation +/- Fracture, without GA, cast 56751 Tibial Shaft Fracture Reduction – no General Anesthetic – Anesthetic Level 2 56752 Tibial Shaft Fracture Reduction – with General Anesthetic cast/traction – Anesthetic Level 2 56800 Manipulation of the Knee Under GA (An example would be a locked knee due to a meniscal tear, manipulated to allow movement while awaiting to see Ortho for investigation +/- repair) 55780 Femur Shaft Fracture Reduction – no GA with cast/traction 55781 Femur Shaft Fracture Reduction – with GA, cast/traction Anesthetic Level 2 53761 Radius/Ulna Shaft Fracture Reduction – no GA with cast (operation only) 53762 Radius/Ulna Shaft Fracture Reduction – with GA- & cast Anes. Level 2 52721 Shoulder (Acute glenohumeral) Dislocation Reduction 52722 Shoulder (Acute glenohumeral) Dislocation Reduction – with GA – Anesthetic Level 2 01861 Patellar Dislocation – Reduction 55712 Reduction of Traumatic Hip Dislocation – with GA – Anesthetic Level 2 55711 Reduction of Traumatic hip dislocation, without GA 53751 Reduction of Elbow Joint Dislocation – no GA 53752 Closed reduction of elbow joint dislocation, with GA – Anesthetic Level 2 53741 Closed reduction of a dislocated radial head/shaft, with GA, cast 54702 Fracture of distal radius +/- ulna +/- dislocation – reduction with GA, cast – Anesthetic Level 2 (Wrist Fracture) 54701 Fracture of distal radius +/- ulna +/- dislocation – reduction without GA, cast (Wrist Fracture) Procedures Tubes and Needles 07145 Intra Osseous IO – Access – Operation Only 01899 & 00199 Miscellaneous Codes – No code exists No Fee: Cricothyroidotomy SY00570 Lumbar Puncture: 12 Years & Under LP SY00750 Lumbar Puncture: 13 years & over LP No Fee: Intubation SY00757 Joint Aspiration – Anesthetic Level 2 00015 Intra-articular medications by injection – tendons, bursa & all other joints 00014 Intra-articular medications by injection – hip No Fee: Central Line Placement 78073 Veno-veno ECMO Insertion 78072 Veno-arterial ECMO Insertion Central 78071 Veno-arterial ECMO Insertion Peripheral 01095 – Arterial Line Placement 32031 – Chest Tube Placement (closed drainage of chest) – Thoracostomy 00526 Insertion of Intravenous Infusion Line in Children Under 5 Years – Extra to Consultation Suprapubic catheter insertion – 08202 Procedures - Comparators No Fee: Cricothyroidotomy 02407 Tracheostomy 01088 – For Anesthesia only No Fee: Intubation 01088 Resuscitation by An Anesthesiologist Requiring Continuous Bedside Care – Per 15 Minutes or Part Thereof S00701 Direct Laryngoscopy 01192 Awake Intubation by Any Means in the Patient with a Suspected or Proven Difficult Airway 02407 Tracheostomy 00017 Insertion of Central Venous Pressure Catheter 78073 Veno-veno ECMO Insertion 78072 Veno-arterial ECMO Insertion Central 78071 Veno-arterial ECMO Insertion Peripheral 07430 Diagnostic Peritoneal Lavage (catheter) (Best Comparator) Reduction of Incarcerated Hernia (Hernia Reduction) 14104 – Delivery Procedures Local Anesthetic 06027 Repair of Torn (split) Earlobe (simple) – Operation Only S00811 Joint injection, aspiration or arthrogram, under radiological guidance 70150 Complicated lacerations of tongue, floor of mouth 01156 Injection Tendon Sheath, Ligaments, Trigger Points: Single injections 01157 Injection Tendon Sheath, Ligaments, Trigger Points: Multiple Injections 01125 Peripheral nerve block – multiple 01160 IV Injections for Diagnosis and/or Therapeutic Management of Chronic Pain Syndromes – Ketamine Only 01110 Anesthesia for Dental Procedures 01159 IV Injections for Diagnosis and/or Therapeutic Management of Chronic Pain Syndromes – local anesthetic only 01124 Peripheral nerve block – single 13600 / 13601(face) Skin or mucosa biopsy – punch 06063 Extraction of foreign body from a wound requiring general anesthesia or procedural sedation – operation only Procedures - Cardiac 00533 ECG Interpretation < 2 Year Old Y33025 Cardioversion – Anesthetic Level 2 Procedures - Miscellaneous 01899 & 00199 Miscellaneous Codes – No code exists 13650 Enucleation or excision of external thrombotic hemorrhoid – Anesthetic Level 2 32031 – Chest Tube Placement (closed drainage of chest) – Thoracostomy Burns / Burn Care / Burn Dressing (Drsg) / Debridement 06078 – Burn Dressing (Drsg) 06079 – Burn surgical debridement-for each 5% of body surface (operation only) 06080 – Burn, subsequent debridement-for each 5% of body surface (operation only) 06082 – Burn, for each subsequent 5 percent of body surface, extra (operation only) IUD Removal – 14541 Nasopharyngolaryngoscopy – diagnostic scope – 00909 07041 -Aspiration: abdomen or chest 06063 Extraction of foreign body from a wound requiring general anesthesia or procedural sedation – operation only P 01883 Trauma-informed comprehensive gynecologic assessment in an Emergency Department Procedures Cutting and Sewing 13611 Minor Laceration or Foreign Body – Requiring Anesthesia – Operation Only 13612 Extensive Lacerations Over 5 cm (use only if the wound length is stated to exceed 5cm, ie "wound length is 7cm") 70150 Complicated lacerations of tongue, floor of mouth 06238 Repair of Complicated Fingertip Injury Under Digital Block or Anesthetic (regional/general) 13610 Minor Laceration or Foreign Body – Not Requiring Anesthesia – Operation Only Lacerations Skin or mucosa biopsy – punch 13600 / 13601(face) 06063 Extraction of foreign body from a wound requiring general anesthesia or procedural sedation – operation only 14109 – C-section or Post mortem C-section Wounds - Avulsed And Complicated (in Special Areas) 06077 Complex lacerations of the scalp, cheek and neck- avulsed and complicated wounds 06076 Nose and Ear – Avulsed and Complicated Wounds 06075 Lips and Eyelids – Avulsed and Complicated Wounds 06027 Repair of Torn (split) Earlobe (simple) – Operation Only 70150 Complicated lacerations of tongue, floor of mouth 06238 Repair of Complicated Fingertip Injury Under Digital Block or Anesthetic (regional/general) 06219 Finger amputation. For those fingers where they have lost the tip and one needs to Rongeur the bone back to ensure an adequate fat pad is created. 02103 Minor lid repair Abscess – Incision and Drainage (in Special Areas) 07059 Abscess – Deep (complex, subfascial, and/or multi-locular) with Local or Regional Anesthesia – Operation Only 07679 Incision and drainage of ischiorectal, intramural, intramuscular or submucosal abscess – under anesthesia – operation only 70084 Pilonidal Cyst or Sinus: Incision and Drainage, Abscess – Operation Only 02447 Incision of peritonsillar abscess: – under local anesthesia – operation only – Anesthetic Level 4 07027 Abscess – Deep (complex, subfascial, and/or multilocular) Under General Anesthesia – Operation Only 07678 Incision and drainage, perianal abscess – superficial – operation only – Anesthetic Level 2 13605 I&D of superficial abscess 07041 -Aspiration: abdomen or chest Procedures Stop Bleeding 02303 Cauterization of Septum: Electric – Operation Only – Anesthetic Level: 3 02341 Posterior Nasal Packing to Include Balloon Control of Epistaxis – Operation Only – Anesthetic Level: 3 02346 Posterior Nasal Packing with Transoral Gauze Pack, Under Local, Topical, or General Anesthetic – Operation Only – Anesthetic Level: 3 Skin or mucosa biopsy – punch 13600 / 13601(face) Repair Fingers and Toes 06238 Repair of Complicated Fingertip Injury Under Digital Block or Anesthetic (regional/general) Requires nail bed repair (includes removal of nail plate, suturing of nail bed laceration and replacement of nail plate) including associated management of distal phalangeal fracture. V07053 Excision of nail bed, complete, with shortening of phalanx 13630 Wedge Resection of nail – Anesthetic Level 2 13631 Removal of nail 13632 Removal of Nail & Destruction of Nailbed 61363 Flexor – primary or secondary repair – first tendon – Anesthetic Level 2 61364 Flexor – Primary or Secondary Repair – Second to Sixth Tendon Repair (extra) 61365 Flexor – Primary or Secondary Repair – Seventh to Eleventh Tendon Repair (extra) 61366 Flexor – Primary or Secondary Repair – Twelfth and Over Tendon Repair (extra) P61368 Extensor – Primary or Secondary Repair – First Tendon – Anesthetic Level 2 61369 Extensor – Primary or Secondary Repair – Second to Sixth Tendon Repair (extra) 61370 Extensor – Primary or Secondary Repair – Seventh to Eleventh Tendon Repair (extra) 61371 Extensor – Primary or Secondary Repair – Twelfth and Over Tendon Repair (extra) 01862 – Toe dislocation – reduction ]

REFERRING MD

[Include this section only if I state that this is an ED consultation, or that the patient was sent to the ER for urgent consultation] [If there is no referring physician known but transcript still specifies this visit is a consultation, use "PCP" and append the following disclaimer at the bottom of this section: "Patient was unable to confirm full name of referring physician, therefore PCP is instead copied on this report. If referring MD is known, I kindly request that this document is forwarded accordingly."] [Referring MD can never be Dr. Alexander Suleiman]

REASON FOR REFERRAL

[ONLY if I state that the patient was referred by another clinician, state the reason for referral by the referring physician. Keep it brief.]

CHIEF COMPLAINT

[Document the patient's primary complaint, including the duration.] For example: Lower abdominal pain for one day.

HISTORY OF PRESENT ILLNESS

(Use bullet points for this section) [If it is explicitly stated that this is an ED/emergency consultation or referral from another physician or nurse practitioner, state when the patient was seen by the referrer (specify if by in person or remotely if stated). Indicate that the referring clinician sent the patient in for emergency consultation and for what reason, (ie: Patient was seen by his family physician in telehealth and instructed to present to the ER for urgent workup of his abdominal pain). If this is a consultation or referral, the documentation should support that the patient was sent for a condition that is complex, obscure or serious.] [Provide bullet points of the patient's current illness, including onset, duration, symptoms, and any relevant triggers or associated factors. In a concise format and Use as many abbreviations as possible. Do not include labs or imaging results in this section, unless transcript explicitly states that results are from outpatient investigations prior to presentation to the ER, such as outpatient labs ordered by GP.]. [If mentioned, include a brief review of systems at the end. Ie: No fever, no URTI, no chest pain or urinary symptoms] [This section should not be used to state all medications patient takes. Medications used by the patient prior to arrival should only be included here if specifically relevant to the complaint, ie: "patient had chest pain which was responsive to nitroglycerin spray PTA" or "patient had breathlessness that did not improve with ventolin administration PTA". Medications used during the emergency room visit do not belong in this section.]

PAST MEDICAL HISTORY

[List the patient's past medical history in a very concise format with only few words, and numbered format.] For example: 1. [Condition 1] 2. [Condition 2] ... n. [Condition n] Use proper medical terminology. for example: "not a big drinker" should be phrased as "minimal EtOH use"

MEDICATION (INCLUDING ALLERGIES)

[List the patient's current medications and any known allergies in a list. If no Allergies, state "NKDA"] Example: [Medication/Allergies 1] [Medication/Allergies 2] always include the statement "See Med Rec for complete list" at the bottom of the medication section.

PHYSICAL EXAMINATIONS

[Section rules: - To maximize billing, separate each system in as much detail as possible DERM, MSK, VASCULAR, NEURO etc. - Include only what the physician explicitly states; do not infer or add negative findings. If there is no info omit it and the corresponding section. - Vitals are first. Do not include any vitals in the subsections, ie PR: 60 does not go in CARDIAC] [if I state normal exam or normal cardiorespiratory exam, or cardiorespiratory exam normal, simply paste this template: "VITALS: (See AMBO record for full list) GENERAL: Appears well, alert, SFS (omit SFS if patient under 3y old) CARDIAC: NS1S2, no EHS, pulses symmetric at radials BIL RESPIRATORY: Normal WOB, GAEB, no adventitious sounds ABDOMEN: SNT, no HSP, no peritonism". For the above template, Include any additional physical findings that are dictated.] VITALS: [Include if noted, otherwise state "See AMBO record for full list"] GENERAL: [Provide a concise assessment of the patient's general appearance in bullet points, ie: ability to ambulate, and skin color, only if mentioned] CARDIAC: [If a specific finding is mentioned, provide concise findings of the cardiac examination, rhythm if mentioned, JVP status only if mentioned, heart sounds, and presence or absence of murmurs. Use bullet points for each finding. Otherwise, do not mention the exam.] RESPIRATORY: [If a specific finding is mentioned, provide concise findings of the respiratory exam, including work of breathing, adventitious sounds, crackles, air entry] ABDOMEN: [If a specific finding is mentioned, provide concise findings of the abdominal examination, including inspection, auscultation, and palpation results. Use bullet points to list observations such as surgical wounds, distension, ascites, bowel sounds, tenderness, hepatosplenomegaly, pulsatile masses, Murphy sign, McBurney Point tenderness, and hernia evidence. Otherwise, do not mention the exam. Exclude subjective statements like "No pain in the belly". They need to be exam findings and phrased in proper medical terminology] [List any other exams mentioned and their corresponding finding under. If a system or heading is not included in the transcript, remove that heading or section.] [Never list historical symptoms or ROS items in the objective section. Objective is exclusively for physician observations of physical exam findings and signs, not for subjective symptoms like nausea, vomiting] - [avoid colloquial language and lay-speech, even if those words are used by the physician. Use proper medical terminology instead, for example: "funny heart rhythm" becomes "arrythmia"] - [layman language to medical terminology in the note] - [do not include items that would not be included in a physical exam, ie ECG findings or patients subjective items ie "nausea" or "headache"] - [Tag conflicting information using by inserting "**REVIEW PLEASE**" (for example - mentioning that abdomen is SNT in physical exam and then saying there is tenderness, tag both SNT and the tenderness in the note).]

INVESTIGATIONS (INCLUDING ORDERS/RESULTS)

[List the investigations performed, their results - Include the "Impressions" section of any CT/MRI/imaging report, with the main takeaway, if available., and any relevant orders. Use as many as abbreviation as possible] For example: - CBCs normal, CRP [Value] - Renal function is normal, liver function is normal. - Urine shows [Findings].

A/P

ASSESSMENT

[Start with a brief identifying statement highlighting the relevant PMH features, their cause for presentation, and their working diagnosis featuring their pertinent positives and negatives in support, ie: "59yo male hx of DLD and CAD who presents with chest pain for 6 hours with a positive troponin and ecg findings of anterior ischemia suggesting NSTEMI.] [Note that relevant results and workup were discussed with the patient or representative, as well as the differential diagnosis and management plan.] [Document the primary diagnosis made in the ER. In a list format] [for each item include the ICD9 code] For example: Subacute SBO Acute coronary syndrome with triple vessel disease - [Under each item, include a brief summary of clinical reasoning for why a diagnosis is favored, as well as alternate diagnoses which are not favored. Always include brief rationale for why any diagnoses are favored or not, but be specific - "PE is not favored due to labs and exam" is too vague, but an appropriate rationale would be "patient has no risk factors for PE and their PERC score is negative". If any clinical decision making tools are mentioned, ie PERC or HEART score, include that commentary here.] - [avoid colloquial language and lay-speech, even if those words are used by the physician. Use proper medical terminology instead, for example: "funny heart rhythm" becomes "arrythmia"] [If stated, include a note at the end with regards to level of patients complexity, for stated reasons such as social concerns (homelessness, drug use), concomitant mental health issues, limited access to care, and/or multiple medical complaints.]

MANAGEMENT AND DISPOSITION

This section outlines the management and disposition following the assessment section above. Include: - [Treatment options, including medications and any specific instructions.] relevant to the current condition.] - [Recommendations from the attending physician, including any follow-up actions.] - [Patient's decision regarding admission or discharge, including conditions for returning to the ER.] - [If captured in the transcript, state briefly what was discussed with the patient, including the relative likelihood of the differential diagnosis, treatment options, and specifically include any shared decision making that the patient executes, i.e. if they opt for watchful waiting and are aware of possible consequences of this decision] [Specify the patient's disposition in very concise format and use as many abbreviations as possible, such as home or hospital admission (if hospital admission not required, say "appropriate for discharge"). Include follow-up instructions with a specific timeframe if applicable, e.g., "Follow up in 24 hours if no improvement." or "Review any outstanding test results with family physician or urgent care". Include any commentary on decision making with regards to the disposition and management plan, ie "given the systemic features including fevers and chills, the patient will be placed on IV antibiotics". When a decision is made with reasoning, cite the reasoning. Write it in list format] Example: - Admit under internal medicine for monitoring - FU 24 hours if no improvement

MEDICATIONS & MANAGEMENT

[For each medication, provide the name, dosage, frequency, route of administration, and duration of treatment. Use a numeric list format to maintain consistency with the input content. Write it in a very concise format and use as many abbreviations as possible. If a dose, frequency, or route are not stated, simply omit these details] Example: 1. Fleet enema 2. Zofran 4 mg TDS SL for four days

REASSESSMENT

[Only include this section if I mention the keyword "Reassessment", or "reassessed", ie "patient is reassessed at 1400h" or "reassessment note, time 1500h". else leave this section EMPTY. NEVER MENTION RESULTS OF ANY LABORATORY TESTS OR IMAGING INVESTIGATIONS IN THIS SECTION!!! PHYSICAL EXAM FEATURES ONLY. Bedside tests such as US or PVR could be included in this section if part of the reassessment] [This note must include why re-assessment is required (ie: "patient is reassessed to evaluate response to analgesia"), and additional history or physical exam findings discovered during the re-assessment that contribute to alteration in treatment plan. Examples might include a COPD patient who is borderline for discharge, whose re-assessment later in their ED stay with new set of vital signs showing poor sats and auscultation showing significant wheezing that helps you decide to admit. Do not specify a time in this note, simply refer to the timestamp above in the timestamp section. If exam features are repeated in the transcript as part of the reassessment, do include these. Always state that the patient was reexamined for this section. Use appropriate language like – auscultated heart and lungs, or serial abdominal exams performed & patient improved from treatment or has not become worse allowing for discharge or requiring admission now.] [If there are no changes noted, state that the symptoms have been stable. Note any response to treatment (e.g., "Pain improved with analgesia, passed walk test"). State the disposition plan, as supported by the clinical information noted in the reassessment. Note specifically if the patient is admitted or if they can be safely discharged.] [This section should never include the results of any investigations, imaging]

RESUSCITATION

[Only include this section if I state specifically that the patient underwent resuscitation, such as "resuscitation time from 1530 to 1545", or "add a resuscitation note". Fluid resuscitation does not count as a trigger for including this section, but the section may contain information such as fluid resuscitation if it occurred as part of the critical care/resuscitation event. Start by stating "Resuscitation start/end time as above". List the the indication for the critical care resuscitation, such as "unstable bradycardia" or "hypotension", or "seizure". Include short form or point form details of observations and treatments pertaining to the critical care resuscitation event. Include a brief exam in an ABCDE format if items are mentioned. ie: "Resuscitation from 1346-1359h for unstable tachycardia" Patient complains of chest tightness, SOB, dizziness. HR 220, BP 70/40. A: Patent, protected. Able so state name and answer short questions B: Dyspneic, single word answers C: Thready, rapid, equal pulses to radials bilaterally D: [use AVPU system if enough information available] E: No evidence of extremity trauma Patient required synchronized cardioversion for unstable SVT. Cardioverted with 200J, synchronized. Sustained NSR afterwards with resolution of symptoms. ]

SPECIALIST CONSULTATION

Include this section only if I state that another doctor or specialist were consulted in real-time (ie by phone or in person). This does not include outpatient consultations whereby patients are referred for outpatient management without a real-time discussion with the consultant. For instance, this statement should not trigger the addition of this section "The patient will be referred to plastic surgery as an outpatient." or "patient was referred to chest pain clinic for cardiology followup" Start with the statement: "Dr. [Specialist name and service, ie Dr. Quinn, General Surgery] was consulted at the time stated above] (1 minute) to review the case and obtain urgent management advice."] If the name of the consultant is not known, simply state their specialty. Do not spell the consultant name out, ie: "S U L E I M A N" State the management plan as advised by the consultant, including patient identifier, reason for the care plan, list of relevant co-morbidities (if any), safety risks, list of interventions, what referrals to be made, what follow-up has been arranged. Afterwards, state: ["The management plan was discussed with the patient/representative."] Specify if the patient will be seen by the consultant in ER, or if call was for review and advice only. avoid colloquial language and lay-speech, even if those words are used by the physician. Use proper medical terminology instead.

PROCEDURE NOTE

If a specific procedure performed by the MD is dictated, include a procedure note. Documentation should outline consent, technique, materials used and any other steps taken so that, should a subsequent complication arise, another physician could deduce possible causes and initiate appropriate treatment. Omit any items that are not mentioned. Clinical notes do not have to be exhaustive, yet must provide an adequate summary of the clinical situation and physicians’ thought processes leading to the diagnosis and plan of care. Note that the patient provided informed consent for the procedure and note indication and risk as stated by the MD. Include said indications and risks as discussed. For procedures like incision/drainage, laceration repair, burn debridement, specify that the area was cleaned/irrigated if relevant. If anesthesia is specified, include the volume and type of anesthesia (ie: 5cc 1% lidocaine was used for a field block). Note any complications or lack there of.

PROCEDURE: COMPLEX LACERATION REPAIR

[(For lacerations that are noted to be complex (trigger phrase: complex laceration, if this phrase is missing, do not include this section), such as those involving the scalp, ear, brow, neck, cheek, first note the billing code for which criteria is met. state explicitly when layered closure is performed, and this was done to close dead space and relieve skin tension for optimal cosmetic outcome and to minimize complications. Where stated, specify the length of the laceration.] [For complex lacerations of the scalp, cheek, neck, specify which criteria are met from the below list: The following conditions are necessary for 06077 to apply: i) A layered closure* is required and at least one of: a) Injuries involving necrotic tissue requiring debridement such that simple suture closure is precluded; or b) Injuries involving tissue loss such that simple suture is precluded; or c) Wounds requiring tissue shifts for closure aside from minor undermining or advancement flaps; or d) Skived, ragged or stellate wounds where excision of tissue margins is necessary to obtain 90 degree closure; or e) Contaminated wounds that require excision of foreign material or f) Lacerations requiring layered closure and key alignment sutures involving critical margins of the eyelid, nose, lip, oral commissure or ear; or g) Lacerations into the subcutaneous tissue requiring alignment and repair of cartilage and layered closure.] [For complex lacerations of the lips and eyelids, specify which criteria is met from the list below: The following conditions are necessary for 06075 to apply: i) A layered closure* is required and at least one of: a) Injuries involving necrotic tissue requiring debridement such that simple suture closure is precluded; or b) Injuries involving tissue loss such that simple suture is precluded; or c) Wounds requiring tissue shifts for closure aside from minor undermining or advancement flaps; or d) Skived, ragged or stellate wounds where excision of tissue margins is necessary to obtain 90 degree closure; or e) Contaminated wounds that require excision of foreign material or f) Lacerations requiring layered closure and key alignment sutures involving critical margins of the eyelid, nose, lip, oral commissure or ear; or g) Lacerations into the subcutaneous tissue requiring alignment and repair of cartilage and layered closure. Layered closure requires at least 2 layers, or 1 layer if including cartilage.)] [06076 Nose and Ear – Avulsed and Complicated Wounds The following conditions are necessary for 06076 to apply: i) A layered closure* is required and at least one of: a) Injuries involving necrotic tissue requiring debridement such that simple suture closure is precluded; or b) Injuries involving tissue loss such that simple suture is precluded; or c) Wounds requiring tissue shifts for closure aside from minor undermining or advancement flaps; or d) Skived, ragged or stellate wounds where excision of tissue margins is necessary to obtain 90 degree closure; or e) Contaminated wounds that require excision of foreign material or f) Lacerations requiring layered closure and key alignment sutures involving critical margins of the eyelid, nose, lip, oral commissure or ear; or g) Lacerations into the subcutaneous tissue requiring alignment and repair of cartilage and layered closure*.] [70150 Complicated lacerations of tongue, floor of mouth Complicated lacerations of tongue, floor of mouth Documentation should support why this repair was considered complicated. A couple of stitches to the tongue would be unlikely to meet this definition; however, a stellate defect, debridement required, anatomical landmarks would all be reasonable inclusion criteria or multi layered.]

PROCEDURAL SEDATION

[Include this section if I state that the patient underwent procedural sedation, or that I sedated them for a procedure, otherwise omit this section. Start by noting the time of the pre-anesthetic assessment, ensuring it is at least 20min before the start time of the actual sedation. Take care not to include simply if I mention that the patient is sedated (ie as part of their physical exam, or as a side-effect of a medicine. Sedation would be an active procedure done by the ERP as a means to facilitate other treatment, ie for an I&D, fracture reduction, or cardioversion] [(Note that the patient provided informed consent for the procedure and note indication and risk as stated by the MD. Include said indications and risks as discussed.] State "NVI pre and post procedure") State "Emergency sedation procedure performed by attending ER physician; no additional physician available. Necessary for immediate stabilization and pain control."]