FAQ's

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I have a questions. I do the registry for Miners Hospital and Conemaugh Hospital. There was a patient who suffered a GLF...

This pt had a self-inflicted GSW from temple to temple with entry and exit wounds. We are having a spirited debate...

As you know, EPIC has different views and screens that everyone can see different aspects of the patient’s chart, if my...

We have a transfer in pt that d/t aortic stenosis needed percutaneous aortic valvuloplasty prior to ORIF of Lt femoral shaft...

This case fits the criteria for wound infection and dehiscence. It was also dx as a surgical site infection and fits the...

Are we required to capture procedures that are performed while the patient is admitted that are not related to trauma or the...

I saw that if you hold the CSTR certification you were awarded continuing education at the PTSF conference. How do I get of a...

We received your emailsto review a couple records; we will go through the records and get back to you. We have two other...

What would I put for “on admission –pupillary response” 1 pupil documented NR 1 pupil couldn’t be checked to...

There was a patient that was a direct admit to the Orthopedic service for a peri-prosthetic transverse supracondylar fx L...

I have tried to code the C5 C6 DISLOCATION o C5 C6 fracture DISLOCATION multiple ways with the fractures and on separate...

We received a record back for correction. It was coded to R SDH with 7 mm midline shift and cerebral herniation when would...

Would a case like this meet inclusion for hospital event #34? I think my old way of thinking has me believing he doesn’t...

I have a pt with the following diagnosis : “LEFT SEPTUM PELLUCIDUM HEMORRHAGE HEAD NFS”. When I try to code it, TriCode will...

You can have one or the other, assisted or unassisted. We want to capture the initial assessment. When both are listed like...

I wanted to clarify that we can use “0” for the unassisted resp rate as documented on the Trauma Flowsheet primary...

We have a hospital that has started to send us patients via wheelchair van when transport via actual ambulance is delayed....

We frequently have patients with multiple contusions or lacerations. It was our understanding unless it was an injury like...

If the consults are called from the ED (not a leveled patient), ex. trauma, neuro and ortho then patient gets admitted to...

It looks like it WAS put in as PTOS in error and actually got submitted. I found it when running reports and changed it to a...

So, what do we do in this case???? Does this mean we only have to look for hourly vitals/neuro outside of that q4 hour...

I’m coding a 3 cm brain contusion on a child 6 years old. In the AIS dictionary, a 3 cm brain contusion in an adult should...

I have a patient that went to the OR for multiple stab wounds 1 in upper left quadrant and 2 flank wounds. She also had them...

Should a spinal epidural hematoma be considered a spinal cord injury for the sequential neurologic...

It is my understanding that the AIS 2005 Coding Course is a requirement of our position. We have been giving our new...

I have an EMS scenario that I would like to run by you. BLS arrives on scene at 01:24, calls for ALS assist. ALS arrives at...

Where can I find the AIS Clarification document?

Would you assist me? R hip, closed reduction , application of Steinmann pin with traction.

Can you direct me where I’d be able to find the guideline from PTSF showing the amount of IRRs and the average that should be...

For EM dispatch time it says the earliest date and time the ambulance was contacted. Would that included receive time as...

Flight crews are starting to give whole blood and I don’t see anything RE: whole blood in the 2019 Operational Manual for the...

Can you please verify for me that if a closed head injury is documented as closed head injury does this mean concussion? Can...

I have a rather odd scenario and would like to get verification from you as to what we should use as the scene...

A 40 year old male was found lying on the floor in his apartment. While being treated by EMS, he got up, walked around and...

As a registry group, we have had much discussion regarding coding spinal cord contusions with fracture(or dislocation) when...

When coding a flail chest – is documentation/mention by a physician required in the chart? Or can we go by the “definition”...

Here’s a question for you…the CT states “Le Fort III variant” but I don’t think I can code Le Fort III according to the CT...

Is there a list of definitions of what makes a interstate highway, i.e. number lanes, divided?

We had a patient come through the ED, got admitted for a pelvic fx, and expired 22 hours of being here (this time starts at...

We recently had a patient who went to a sister hospital ED and got transferred to us as a direct admission, and then got...

Could you please guide me to the correct code for "subfalcine herniation of the cingulate gyrus?"

I am clarifying AKI hospital event to someone and wanted to make sure I am delivering the clarification correctly...

What is the code for a patient that is pushed intentionally from a moving vehicle?

We have been capturing the trauma surgeons and APs on this screen regardless of whether the called time and/or note time fall...

We noticed that the spinal cord injury pre-existing condition lists all parts of the spine EXCEPT cervical....

I have a quick question regarding the “intrathoracic surgery” on the procedures tab whenever you get time. We do NOT pick...

When a patient has an unwitnessed fall with possible head strike and the only injury listed is a headache by the ED RN may the..

How would you select yes or no to the question Is there hourly documentation beginning with ED arrival?

Would you consider this air embolism as a hospital event, Iatrogenic vessel injury? There was no further consequence of it...

For return to OR…. Does the patient physically have to leave the OR and return, or does the patient meet criteria if the...

When physician is charting a LOC throughout the chart but not specifically stating concussion, there was a term(s) that could..

Why does a “red flag” pop up if I document that the ED physician is present before the patient arrives? Wouldn’t that indicate..

If we have an insurance listed as “Amish under agreement” meaning that the Amish church/community that the patient is a part...

we have a patient who comes in frequently with burns from huffing keyboard cleaner. She had a documented history of “Inhalant...

Please help me with a code for “electric bicycle vs car."

Would you consider this patient PTOS? Pt was admitted to trauma OBS for over 2 days , assaulted with boxcutter and sexually...

I have a patient who was standing in the ocean when a wave knocked her over causing injury being captured in the registry...

Scenario: Patient is admitted as a trauma with a previous kidney transplant (2 years ago). However, they are in kidney...

I have a question regarding hospital event entry? We have a patient who was confirmed to have hospital event ( major...

If you have a patient that exhibits tremor, sweating, agitation, confusion and hallucinations with a document history of...

If it is an ambulance Helicopter rendezvous from scene to Hospital. Which is the correct way of documenting it in collector?...

If a patient is transferred out, even with no injuries being found at the transferring hospital, why would that not be...

I have a question about whether a patient in our registry should be PTOS. The patient I am doing is a transfer from an OSH...

The patient was getting into her car when her purse got hooked on the gear shift. The car began moving and rolled over the...

Am I mistaken that there isn’t one good code for an emergent bilateral clamshell thoracotomy that doesn’t have a further...

When Medical records state no insurance on file-I’ve been using Unknown for payor class, then would go back within 30 days...

We are now routinely updating collector data and resubmitting diagnoses after we receive our autopsy results. If we are...

I received an autopsy report today from a DOA to our facility from a pediatric abuse case. Since he was DOA we did not do any...

Bedbound Pt transferred from outside facility ED due to bruising on LE. Gets admitted to our ICU. Dx: Bilateral femur fxs...

Pts with Hx of COPD that may or may not be DNR, who have mechanism of injury, with AIS codes, admitted to Step Down or ICU...

I have the radiologist and the Trauma H+P stating there is a Lefort 2 fracture but upon review of the AIS book I don't have...

I have a patient that was an unwitnessed fall with head strike that came to the hospital via POV. The patient was made a....

I just wanted to check to make sure that there is not a problem with our Data submissions. The status usually says...

NS called while in the ER and the PA responds while in the ER but the MD does not see the patient until the next morning on...

What would you do in this situation: Paramedic on board – you’d pick up ALS as highest level of provider Patient was offered...

Can you please clarify the Cardiac Arrest with CPR Hospital Event?

Question, for transport accidents ( pedestrian VS MV; pedal cyclist VS MV) with no documentation as to where they occur (on...

Could you provide guidance as to if this patient should be picked up as a PTOS patient or not. Scenario: Patient was at a...

I have a question regarding PTOS inclusion regarding a DNR case. Patient presents with neuro symptoms and CT reveals head...

I’m wondering if you can help us with an inclusion question. Should a patient who was already seen, treated for their injury...

We had a patient transferred in to our hospital: • Cardiac patient admitted at outside facility • Fell in the hospital and...

If I don’t have MR for referring facility but I have a PCR that has vitals on while the patient is still physically in the ED...

We had a pt come in after an MVC and when the initial CT of the head was done, it showed a small SAH. When his repeat within...

I am in a bugger of an OR report, and struggling with the awful “control vs. more definite root operations” guideline....

Could you please tell me what all “spinal cord injuries” we capture when we answer yes to the sequential neurological...

While running reports looking for ambulance/helicopter providers, we noticed that there are a few from New Jersey. Can other...

In Outcomes, records will fail to import if there isn’t a descriptor w/ the EMS agency or destination facility. So for...

I have a case where the pt. was at another trauma center, developed pneumonia, unplanned intubation, sepsis, ARDS, and major...

I have a peds patient who was in a golf cart accident with head injuries. I have defined SDH and skull fx injuries. One....

6/7 he has an aspiration event that caused respiratory arrest. During intubation “abundant emetic content in the vocal cord...

How are we to abstract a pregnant mother and baby injured in a MVC if the baby dies at the hospital after delivery?

We have someone treated at another hospital and discharged. Now at our hospital ( for 1st time) requiring treatment for the...

I’m having a hard time with making this one particular patient a Non PTOS. Patient went to XXX Hospital for an...

Does the "Did patient have a craniotomy for trauma?" element include craniectomies?

Some of our patients for weird re-occurring subdurals may require treatment by way of MMA embolization. Can you confirm that...

I have a clarification question regarding ICH with word “lobe” in the Dx description, and wanted to make sure correct codes...

If I have a patient who has a GSW to his arm and the OR record indicates Brachial Artery Thrombosed x 2 and the OR surgeon...

We are looking to properly code a person who fell off a treadmill while the patient was running on it. The location was in...

A question came up regarding when a patient comes in from a Skilled Nursing Facility and then is discharged back to the same...

I have difficulty building reports in Report Writer. Is there something out there with step by step instructions?