Wilson Apollo gave an excellent presentation at the 2016 NCRA meeting assisting CTRs in coding radiation therapy. This has been a much needed educational experience in our field as registrars and Radiation Oncologists are not always on the same page when it comes to correct coding. Below, we have some highlights from the presentation. IMRT not always mentioned in RT Treatment Summary. Important to look in…
Persistent Hypotension
Persistent Hypotension is determined by hypotension that persists in the hour after the conclusion of the 30 ml/kg Crystalloid Fluid Administration: The end time of the fluid administration must be determined. This may be clearly documented in the chart or may need to be calculated by the abstractor. Review the systolic blood pressure readings and mean arterial pressure readings (MAP) beginning at the end time of…
Septic Shock Present Based on Lactate Level
As with Severe Sepsis, Septic Shock presentation can be determined based on provider documentation OR on clinical indicators. To determine the presentation of septic shock: First you MUST have Severe Sepsis Second you MUST have EITHER An Initial Lactate Level >=4 {if the lactate level is the last indicator use result time} OR Hypotension prior to crystalloid fluid administration and hypotension that persists within one hour…
EMS / Ambulance Documentation Q&As
Question 136: Are we allowed to use fluids administered by Emergency Medical Services (EMS) in route to our facility? Answer 136: Yes, depending on the rate at which they are administered and whether or not there is an order or protocol that serves as an order. Fluids must be given at a rate greater than 125 ml/hour (equivalent to 1000 ml…