Emergency Medicine Notes

[Karleen Chura]

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Objective: Language used by providers in medical documentation may reveal evidence of race-related implicit bias. We aimed to use natural language processing (NLP) to examine if prevalence of stigmatizing language in emergency medicine (EM) encounter notes differs across patient race/ethnicity.

Methods: In a retrospective cohort of EM encounters, NLP techniques identified stigmatizing and positive themes. Logistic regression models analyzed the association of race/ethnicity and themes within notes. Outcomes were the presence (or absence) of 7 different themes: 5 stigmatizing (difficult, non-compliant, skepticism, substance abuse/seeking, and financial difficulty) and 2 positive (compliment and compliant).

Conclusions: Using an NLP model to analyze themes in EM notes across racial groups, we identified several inequities in the usage of positive and stigmatizing language. Interventions to minimize race-related implicit bias should be undertaken.

With extremely high stakes and little room for error, the ED is a fast-paced, challenging care setting. The influx of new patients in the ED leaves almost no time for charting or taking notes, and 62% of emergency clinicians have experienced symptoms of burnout.

The information and statements set forth herein are based on data collected from actual users and reflect the real-life experiences and opinions of such users, but are not intended to represent or guarantee that any user of our products and/or services will achieve the same or similar results. The experiences are personal to those particular users and a number of factors, which have not been taken into account, may affect your personal experience and results. We do not claim, and you should not assume, that all users will have the same experiences. The statements set forth herein do not form part of or constitute an offer or contract.

WikEM mobile app access is moving to Eolas! Our website will remain the same, but for mobile app users, this transition will offer an improved user interface, as well as additional in-app content such as MDCalc and a host of published guidelines. Download the free Eolas app now to ensure uninterrupted mobile app access.

The goal of the Global Emergency Medicine Curriculum Project is to become the go-to place for emergency medicine curriculum development. Like any Wiki, it is open to all who wish to contribute. The emphasis is on Free Open Access Medical Education (FOAMed). This is NOT a textbook of emergency medicine. It is a catalog of on-line resources. To read and contribute to the open-access textbook, go to Notes by Category in the left column. The Global Curriculum Project is a living resource in constant flux as new data becomes available and older data becomes obsolete.

Presented in a user-friendly format, combining flowcharts and high-quality illustrations together for an easy-to-read experience, this fifth edition of The RCEM Lecture Notes: Emergency Medicine has been thoroughly revised to reflect recent advances in the field of emergency medicine and to give readers a comprehensive and highly accessible overview of the field.

Wiley Medical Education books are designed exactly for their intended audience. All of our books are developed in collaboration with students. This means that our books are always published with you, the student, in mind.

Catherine Williams, FRCEM, Consultant in Emergency Medicine with dual accreditation in Paediatric Emergency Medicine, Royal Bolton Hospital. Training programme director for Intermediate Emergency Medicine training, Health Education North West.

This 5th Edition is edited by Catherine Williams and Amy Nickson, has been revised and updated by contributors, and is based on the 4th edition of Lecture Notes: Emergency Medicine which was authored by Chris Moulton and David Yates.

After an extensive two-year analysis of the updated E/M Services Guidelines, the ACEP Coding Nomenclature Advisory Committee (CNAC) has produced this comprehensive set of FAQs. CNAC consists of over 30 board-certified emergency physicians and certified professional coders who bring a wealth of expertise in emergency medicine coding and billing practices. The committee has conducted a thorough review of the E/M coding guidelines as outlined in CPT and has incorporated additional insights from resources such as CPT Assistant, AMA webinars, and the AMA CPT Symposium.

The American Medical Association (AMA) has recognized the significance of ACEP's efforts through CNAC by awarding them the 2023 Educational Excellence Award. This distinguished award acknowledges the quality of ACEP's educational content and the impact of CNAC's contributions to the practice of medicine.

It is important to note that this FAQ is a living document. Since its initial release in October 2022, the document has undergone several revisions. CNAC remains committed to continually updating and refining this resource to ensure it stays current with the latest industry standards and practices.

The nature and extent of the history and physical examination are determined by the treating physician/Qualified Healthcare Professional (QHP). Importantly, the extent of history and physical exam documented is not used to assign the E/M code.

CPT has not published clinical examples for the COPA elements. In addition, the clinical examples for the E/M codes in Appendix C will be deleted from CPT in 2023. The ACEP Coding and Nomenclature Committee has reviewed available CPT guidelines, AMA clarifications published in CPT Assistant, and common practices in the emergency department to offer some guidance when assessing the Complexity of Problems Addressed.

"Stable" for the purposes of categorizing MDM is defined by the specific treatment goals for an individual patient. A patient who is not at their treatment goal is not stable, even if the condition has not changed and there is no short-term threat to life or function.

For physicians and coders working in the emergency department, a patient that requires hospitalization seems out of place in the Low COPA category. AMA CPT personnel have said that this bullet was added to provide a mechanism to score Low MDM as required for the inpatient hospital/observation E/M codes. This bullet should not be used when calculating the MDM for patients in the emergency department.

This concept can be applied to many evaluations for patient complaints that should be considered at least Moderate COPA. The following are some examples, but this is not an all-inclusive list:

It is important to recognize that all of these presentations exist within a clinical spectrum of severity. At the moderate level, diagnostic evaluations for these would likely involve simple testing, such as plain x-rays or basic lab tests.

The final diagnosis for a condition, in and of itself, does not determine the complexity of the MDM. The presenting problem, or diagnostic evaluation, or treatment or management, or differential diagnoses, may indicate that an extensive evaluation is required to reach the conclusion that the signs or symptoms do not represent a highly morbid condition.

The following high COPA examples may be demonstrated by the totality of the medical record as demonstrated implicitly by the presenting problem, or diagnostic evaluation, or treatment or management, or differential diagnoses, or overall medical decision making, as demonstrated in the entire record.

It is not necessary that these conditions be listed as the final diagnosis. An extensive evaluation to identify or rule out these or any other condition that represents a potential threat to life or bodily function is an indication of High COPA and should be included in this category when the evaluation or treatment is consistent with this degree of potential severity.

Yes, physicians may be cautioned against documenting possible, probable, or rule-out diagnoses because these conditions cannot be used for ICD-10 coding in the emergency department, other outpatient settings. However, these rule-out conditions illustrate the significance of the complexity of problems addressed and justify the work done, especially in situations where the final diagnosis seems less than life-threatening. Per CPT:

Yes, the physician/QHP may employ risk stratification tools to ascertain the significance or severity of a presentation and/or help determine appropriate diagnostic or therapeutic interventions. Some tools that may be relevant to emergency medicine are:

Pregnancy in a patient can significantly impact the complexity of presenting problems and the risk associated with treating the patient, even when the chief complaint is not directly related to the pregnancy. This is primarily due to the physiological and anatomical changes that occur during pregnancy, which can influence the management and outcomes of various medical conditions.

Additionally, pregnancy can influence the interpretation of diagnostic tests and imaging studies. Hormonal changes during pregnancy can affect laboratory values, making it essential for healthcare providers to consider pregnancy-specific reference ranges when interpreting test results. Furthermore, the presence of an enlarged uterus can impact the accuracy and interpretation of signs and symptoms of diseases such as trauma, appendicitis, renal colic, and pyelonephritis, as well as imaging studies, potentially leading to diagnostic challenges or the need for additional investigations.

Moreover, the potential risks associated with treating a pregnant patient must be carefully considered. Medications and interventions that are typically safe for non-pregnant individuals may have adverse effects on the developing fetus. Healthcare providers must exercise caution when prescribing medications, ensuring the safety of both the mother and the unborn child. Additionally, certain diagnostic procedures, such as radiation-based imaging or invasive interventions, may carry increased risks to the fetus and require careful consideration of the potential benefits and harms.

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