Critical care documentation
Background
- Multiple components must be satisfied and appropriately documented in the medical record when delivering critical care in the ED.
Elements of Critical Care Time
- Critical illness or injury = illness or injury that impairs one or more "one or more vital organ systems such that there is a high probability of imminent or life threatening deterioration in the patient’s condition.”
- Critical care services = direct medical care for the patient that involves “high complexity decision making to assess, manipulate, and support vital organ system failure.”
- CMS additionally mandates that for medicare patients, "the failure to initiate these interventions on an urgent basis would likely result in sudden, clinically significant or life threatening deterioration in the patient's condition".
- Time = total time spent evaluating, managing, and providing care to a critically ill patient. Does not have to be continuous. Includes direct patient care at bedside as well as time spent reviewing test results, discussing the case with consultants or family members, and documenting in the patient's chart.
Critical Care Diagnoses
The following diagnoses may qualify for documenting critical care time:
- Active Seizures / Status Epilepticus
- Acute Altered Mental Status / Unconscious
- Acute GI Bleed
- Acute Stroke
- Anemia requiring transfusion
- A fib with RVR
- Cardiac Arrest
- Delerium tremens
- DKA
- Ectopic pregnancy
- Hyperkalemia requiring acute intervention
- Hypovolemic shock
- Intracerebral Hemorrhage
- Moderate to Severe Asthma
- Moderate to Severe CHF
- Overdose requiring reversal agents
- Pneumothorax
- Pulmonary embolism
- Respiratory distress requiring BiPAP or intubation
- Sepsis
- STEMI
- Suicidal ideation with immediate threat
- SVT
- Unstable angina