tci ED Coding & Reimbursement Alert - 2000 Issue 5

Documentation of ED Encounter

EMS Prehospital Care Report Form: Call Received911/Dispatch; Aid Before ArrivalFirst Aid, No Prearrival Instructions; Code to Scene3; Incident SiteOther/Laundry; Nature of CallCardiac Arrest; TransportPatient was Transported, Yes; Past Medical HistoryUnknown; Total Scene TimeNo indication; Personal Protective EquipmentGloves; Glasgow Coma Score-3, Invasive ProceduresEndotracheal Intubation (ET) and IV; Entered into Trauma SystemNo. Emergency Room Outpatient Record FormMedical Screening ExamNursing Notes: Time19:08: Patient in code 99 (arrived) via EMS. CPR in progress. Patient has an established IV in LAC, is intubated and being bagged. Patient was found unconscious, unresponsive at a local mini-market. EMS reports patient may have been down for more...

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