FAQ's

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Mechanism of Injury in cases of abuse

When should we be picking up MTP?

Question regarding Organ Donation

If we have a patient that is going home (SBF) but on Hospice. How do we answer Discharge Destination?

Do we need to answer question on additional NTDB elements re: transfer to NTDS?

I have an OR note that states that a tourniquet “applied” but not inflated at all during OR”. Do I pick it up?

I am trying to code a burn of 9.5% but it is rounding up and applying an incorrect code for 10% + burn?

Can I ask for a quick clarification on the Unplanned Visit to the OR?

Question on Multiple Procedures: Bladder Repair

Do you know of any specific references describing ISS and mortality prediction?

Can you give me a little info on the AIS 2015 and how it will affect current registrars?

Who uses the data that PTSF collects?

Can we close 2020 records before having the updates installed ?

Can you tell me what “other” refers to in the Core Measures report under ED Response?

Change in recording GCS qualifiers in 2020

Blunt vs. Penetrating for blast type injury from firework

We have a patient transferred in from another facility via EMS who only has a FFS isolated hip fracture, would she be PTOS...

I have a patient that was discharged back to her supervised residential facility and do not see the location in the facilities..

We had a meeting yesterday to go over the changes for the 2020 patients and we have a few questions.

I was hoping you could help us clarify when a patient gets injured while jumping on a trampoline. ...

This patient went to a OSH after wood “kicked” back into his abdomen - was seen, admitted, followed by surgery at OSH...

So the concern is PTOS vs NonPTOS: 50 yo Male puncture wound to right index finger

Can you please clarify the element “called” in consults. The collector has only call time, we have some confusion when call was.

If patient expired in ED and no insurance info on file, do we select Unknown or selfpay?

In the case of a patient that fx’s a bone, Ortho signs off saying that the patient can be treated as an outpatient and can be...

Question, does nonsustained VT meet Major Dysrhythmia definition? The manual has examples, that include sustained, which now...

We had a patient today who fell and dislocated their HIP PROSTHESIS. My brain tells me to pick this patient up – it is a...

We have a 7 week old baby who presented to ED as a “fall”. The ED suspected abuse, did 2 scans – which identified no injuries...

We have a patient who is a GSW to the head. The registrar coded correctly, 140692, >2cm penetrating to the Cerebrum but we...

At our facility, we used to collect the vital signs documentation on a quarterly basis. At the Fall conference, it was a...

I have a question in RE: to primary & secondary cause of injury on a particular pt. He fell 3’ from a ladder onto metal...

When being discharged from the ED, patient had a syncopal fall and required CPR. Patient was then admitted to ICU for cardiac...

for the Abuse question…we always end up in discussions about this… are we looking at Kids and Elderly and other protected...

For the comorbidity of Social Anxiety…must it be just Social Anxiety? And does mention of prescribed meds/therapy for the...

Can you give any more clarification about the Delirium event? We are trying to clarify this for patients who sundown, patients w

Is a wheelchair transport van that brings a patient from another acute care facility now considered a transfer in? Or no?...

I have a patient that was intubated for his OR procedure only. Was extubated and stridored, requiring re-intubation. This...

If I have a patient who could not have chemical DVT Proph and they placed an IVC filter instead should I be capturing that...

Pt sustained GSW to thorax & abdomen area. Pt has “hole in the central tendon of diaphragm” No measurement is given. Would...

Could you please provide your expertise on this case below. 26 YO M Right elbow distal humerus fx after throwing a softball....

We have a unique situation that we need clarification on. A patient came to our facility after a fall, had care, and the...

How is timeliness of submission plotted on the control charts we receive?

We had a patient that was ~ 32 weeks pregnant come into the trauma bay as the result of an MVC. A C-section was performed...

We have a pt who was discharged to Bucks County Correctional Facility Mental Health Unit, do you have a facility number for...

We have had more patients getting transferred in from our sister hospitals. Under the prehospital tab, would that be the...

We had a patient that went to the or for a hip. The ortho MD put him in icu after to be watched more closely. The order he...

If I have a patient that was unrestrained per the pcr and there is no mention of the air bags how would you answer the...

I have a situation where a patient fell and a week later called the ambulance to be taken to the hospital. The patient is a...

Do you have an accurate number of data elements the registrars enter per case?

There was a patient who suffered a GLF that was taken to our ED. The only finding from imaging was a left intertrochanteric...

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..