About Sean Dyer, MD

Emergency Medicine Chief Resident
Department of Emergency Medicine
Cook County EM Residency Program
2 11, 2016

ED Charting and Coding: Review of Systems (ROS)

2016-11-28T13:36:31+00:00

review of systems medical-chart-canstockphoto13003631-ros

The Review of Systems (ROS) was the most frustrating aspect of charting as an intern. Documenting at least 10 elements from systems seemingly unrelated to the chief complaint took as long as a physical exam and was much harder to remember. For efficiency, many of us include any pertinent positives and negatives in the history of present illness (HPI) and use an ROS caveat such as “10/14 Review of Systems completed and is negative except as stated above in HPI (Systems reviewed: Const, Eyes, ENT, Resp, CV, GI, GU, MSK, Skin, Neuro)” or “A complete Review of Systems was obtained and is negative except as stated in HPI.

This obviates documenting 10 or more separate systems, but what if you’re at a site where the coders won’t accept a blanket phrase? Should you keep your lengthy HPI and then chart the same info again? Or can we devise a ROS that is at a minimum not redundant, and perhaps even helpful?

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5 09, 2016

ED Charting and Coding: History of Present Illness & Past Medical, Family, Social History

2016-11-28T13:40:50+00:00

medical chart history of present illnessRemember the “OPQRST” mnemonic? It stands for Onset, Provocation/Palliation, Quality, Region/Radiation, Severity, Timing. Not only can it guide your history taking, but charting these descriptors also ensures you can code at an appropriate level. The patient’s history is the first example of the balance between essential information and over-documentation. It should be comprehensive, yet be chief-complaint focused [1]. Below, we outline the components of a thorough and billable history.

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15 08, 2016

PV Card: Introduction to ED Charting and Coding

2017-08-01T19:52:43+00:00

ED charting and coding computer-charting-TEXT-canstockphoto17902161What makes a good chart? How do you write a good chart quickly? How about a good, efficient, billable chart? On average, residents and practicing physicians report they did not receive adequate training in charting and coding1–3 and resident charts are more often down-coded due to documentation failures than those of attendings and PAs.4 Thankfully, resident education in charting has improved over the past 15 years,5 and a little learning goes a long way to improve confidence6 and competence.7

In the spirit of #FOAMed, we would like to provide some pearls and pitfalls for EM documentation, starting with a PV card that addresses the basic elements of coding a chart. We hope it’s a handy on-shift reference.

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3 08, 2016

A Starter’s Roadmap to EM Resources: Books, Websites, and Apps

2017-10-13T15:04:35+00:00

Roadmap to EM Resources text-road-map-canstockphoto6514821With the start of the year, we welcomed a new group of faces into our respective residency programs. We can all still remember how daunting it was to tackle learning the immense volume of material to be a great emergency medicine physician. We have so many amazing resources, but no road maps for where to start. The purpose of this list is to help guide the new interns as well as to highlight some resources that even the more seasoned clinician may find useful.

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