EMS documentation

smurphy@augustahealth.com

If a patient is in respiratory failure in the field (sat 80% ra, resp- 28) and on arrival to the ED they are no longer in distress (sat 94% 2lpm, resp-20), do you code respiratory failure based on the EMS information?

hooter1964

Great question, I would query the provider and provide the EMS info, as well as the current status in the ER.  If the ER physician documented acute respiratory failure I would report it.
Makes me think of how many times nausea vomiting diarrhea is reported at home and the patient is diagnosed with Gastroenteritis,and yet the patient never displays any of those symptoms in the hospital but its coded as the reason for admission.