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Loredana Lecciso : "Presto tornerò a casa, a Cellino San Marco" | M.C.G.S - Duration: 7:01.
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Living with diabetes isn't easy. - Duration: 1:19.
See this? This is diabetes.
And living with it...Is easy!
Oh no, not for me thanks! See? Easy.
Ohh, that feels good. Do you know what else feels good?
Everything! I'm in complete control of my life.
I can have a nap whenever I want. My friends and family completely understand.
Do you know who else understands? My boss.
Hi. Yes. I can't make it in today, I'm just too tired. Okay, thanks.
See? Easy. Easy!
Easy! Easy! Easy! Easy!
Easy! Easy! Yah! Easy!
It's so easy! Easy! It's Easy! Easy, easy, easy!
It's so easy! Easy!
See? Easy!
Diabetes, it's easy!
-------------------------------------------
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Why "Ginger Tea" GOOD FOR MEN | Amazing Health Benefits Of Ginger - Duration: 2:33.
Why "Ginger Tea" GOOD FOR MEN | Amazing Health Benefits Of Ginger
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How to replace pollen filter NISSAN X-TRAIL T30 TUTORIAL | AUTODOC - Duration: 5:06.
Use a torx №T25
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Opel KARL 1.0 Start/Stop 75pk Innovation - Duration: 1:01.
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Option Trading Course
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Focused Review of Sections B, C, H, J, and O (Influenza) - Duration: 58:24.
»» We'll spend the next hour reviewing Sections B, C, H, J and O including influenza.
And again, as in all the other presentations, this is a list of the acronyms that we'll
be using.
In the presentation, we will identify and explain the intent of each of the sections
and discuss the coding instructions and required information for Section B, Hearing, Speech
and Vision.
Section C, Cognitive Patterns.
Section H, Bladder and Bowel.
Section J, Health Conditions, Falls.
Section O, Special Treatments, Procedures and Programs, Influenza Vaccination.
And then we'll do some practice coding for these sections.
At the end of the presentation, you should be able to demonstrate a working knowledge
of each of these sections as well as state the intent of them, and then apply your coding
instructions to accurately code practice scenarios.
So first we'll look at Section B, Hearing, Speech, and Vision.
Specifically for Section B, our objectives today will be to describe the intent of the
section, explain the revisions to item BB0800, and use the guidance to accurately code our
practice questions.
The intent of Section B is to document the patient's ability to understand and communicate
with others.
This is accomplished by collecting data in three sections.
B0100, comatose.
BB0700, expression of ideas and wants.
BB0800, understanding verbal content.
Section B is intended to document the patient's ability to understand and communicate with
others in his or her primary language whether in speech, writing, sign language, gestures
or a combination of these.
It can be challenging to differentiate between these sections.
And data needs to be collected and reported for each.
In this section we'll go into more description of the sections and provide some examples
to help us with coding Section B. So we'll start with some clarifications.
Between v3.00 and v.4.00 of the LTCH CARE Data Set there are no changes with the first
two items B0100, comatose and BB0700, expression of ideas and wants.
For Section BB0800, a clarification has been provided with the addition of understanding
non-verbal content as opposed to only verbal.
This is of course tremendously helpful with our patient populations because we have so
many adaptive devices and methods for communication with our patients.
And this language now allows us to capture those.
While there are no changes made for B0100, comatose, we'll offer a new coding tip and
an example.
This scenario applies to an admission and planned Discharge Assessment and the reason
for the data collection is because patients who are in a coma or a persistent vegetative
state are clearly at increased risk for mobility complications as well as others.
So for B0100, we will use the code 1, Yes, for a diagnosis of coma or persistent vegetative
state, which is documented in the patient's medical record.
Review the medical record to determine whether a diagnosis of coma or persistent vegetative
state has been documented by a physician, nurse practitioner, physician assistant, or
clinical nurse specialist as allowable under your state laws.
You would code 0, No, if a diagnosis of coma or persistent vegetative state is not present
on admission or discharge.
We have some other common diagnoses that have similar symptoms but are not the same as coma
or persistent vegetative state, such as some of the progressive muscular neurological disorders.
So it's very important that we have it specifically documented as coma or persistent vegetative
state in the medical record.
So here's a coding scenario for B0100.
Mrs. M was admitted to the LTCH and is non-communicative and often sleeps.
Mrs. M's medical record includes a diagnosis of Alzheimer's disease.
Mrs. M's medical record does not include a diagnosis of coma or persistent vegetative state.
So how should we code B0100?
You'll code 0 for no?
And code 1 for yes?
Just a few more responses.
So 95% of us chose code 0, No.
And this is of course the correct answer.
We code no if a diagnosis of coma or persistent vegetative state is not present at the time
of admission or discharge.
And here we offer the rationale for how we coded this coding scenario.
Because there is no documentation in the medical record that states Mrs. M's diagnosis includes
coma or persistent vegetative state, No 0, is the most appropriate response.
The next section we'll review is BB0700, expression of ideas and wants.
This is completed on admission and planned Discharge Assessments.
And this is what it appears to look like on the LTCH CARE Data Set.
So let's try a coding scenario for BB0700.
Mr. B had a stroke several weeks ago and has a diagnosis of expressive aphasia.
The certified nursing assistant asks Mr. B if he wants help with bathing.
He looks at the certified nursing assistant and smiles, but does not respond verbally.
The certified nursing assistant reports to the nurse that she has not been able to determine
Mr. B's preference and needs help with his needs with any of his activities of daily
living since he was admitted the day before.
The nurse interacts with Mr. B and determines that he rarely expresses himself.
The nurse plans to collaborate with the speech language pathologist and other team members
and Mr. B to increase Mr. B's ability to express himself.
How would you code BB0700?
And our choices for BB0700 include coding 4, expresses complex messages without difficulty
and with speech that is clear and easy to understand.
Code 3, exhibits some difficulty with expressing needs and ideas or speech is not clear.
Code 2, frequently exhibits difficulty with expressing needs and ideas.
Or code 1, rarely/never expresses self or speech and is very difficult to understand.
Okay. So let's see how we did.
96% of you chose D, which is code 1 rarely/never expresses self or speech and is very difficult
to understand.
And that is of course the correct answer.
And the reason that we would choose this in the scenario is that due to Mr. B's expressive
aphasia.
He's unable to verbally express his needs.
That was indicated by both the CNA as well as the nurse.
Okay.
So BB0800 is our next section, understanding verbal, and now in addition non-verbal content.
This section is completed for admission and planned discharge as well.
As mentioned, any inability to understand a person-to-person communication can impact
our patient's well being including their association with other people, and their ability to follow
their health and safety instructions.
So here's a coding scenario for BB0800.
Mr. T sustained an acquired brain injury and is on an invasive mechanical ventilator.
Mr. T uses an electronic communication device to respond to staff and family questions.
Staff members report that he only understands basic conversation.
The staff needs to simplify all communication for him to understand what is being asked.
The family reports that simple and short messages are necessary during their conversation to
elicit accurate responses.
How would we code BB0800 in this scenario?
And our options are coding 4, Understands.
Code 3, Usually understands.
Code 2, Sometimes understands.
Or Code 1, Rarely/never understands.
So on this one we had 60% choose B, Usually understands.
And 36% choose C, Code 2, Sometimes understands.
So our correct answer is, C, Sometimes understands.
So let's go through our rationale for why we would pick Code 2.
In this situation, Mr. T uses his electronic device to indicate his understanding of only
basic conversations or simple direct phrases.
He's really understanding only the most basic conversations and direct phrases that are
directed to him.
Okay.
Here's another coding scenario for BB0800.
Mrs. K is recovering from the surgical removal of a cancerous brain tumor and has severe
hearing loss and some cognitive limitations.
The staff, patient, and family use an electronic device to communicate with her.
Staff members and family reports that Mrs. K on a few occasions required visual cues
to understand what is typed into her electronic device in order for her to respond accurately
to questions.
Mrs. K can understand most conversations with the use of her electronic device.
How would you code BB0800?
And for this we should choose from Code 4, Understands.
Code 3, Usually understands.
Code 2, Sometimes understands.
And code 1, Rarely/never understands.
Okay.
It looks like everybody has made a selection.
So 92% chose the correct answer which is code 3, usually understands.
So let's go through our reasoning for that selection.
3, usually understands.
In this scenario the patient understands most conversations but misses some part or some
intent of the message and requires some cues at times.
Mrs. K and her family use the electronic device to communicate and she's understanding most
of the communication with some cues, which makes 3, usually understands, the most appropriate
selection for her scenario.
So just summarizing Section B. Section B has not changed.
There does exist one clarification for BB0800 to include non-verbal content in addition
to verbal content.
But otherwise the section is unchanged.
Next section will be Section C, Cognitive Patterns.
So in this section we're going to define Section C and explain its intent and rationale.
We'll discuss coding instructions and required information for the items.
And we'll apply the coding instructions to accurately code practice scenarios.
Section C is intended to determine if a patient has the signs and symptoms of delirium using
the standardized Confusion Assessment Method or CAM.
The section on the LTCH CARE Data Set has a shortened version of the CAM to guide the
user to complete all requirements.
It includes A-E for completion with yes/no responses required for each.
There are some subtleties to be aware of in Section C. Delirium is often misdiagnosed
as dementia, or it can be.
However patients who truly have dementia can also experience delirium.
A recent deterioration in a cognitive function of a patient may indicate delirium, which
may be reversible if detected and treated.
Delirium can be the symptom of an acute treatable illness such as the case of a urinary tract
infection or an adverse reaction to medication.
Therefore detecting delirium in a timely manner can help clinicians determine acute changes
in condition that can then be treated by eliminating the source.
It's important to understand the definitions in Section C. Delirium is defined as a mental
disturbance characterized by new or acutely worsened confusion, disorganized expression
of thoughts, change in level of consciousness, or hallucinations.
Fluctuation is defined as the behavior that tends to come and go and/or increase or decrease
in severity.
The behavior may fluctuate over the course of an interview, discussion, or the assessment
period.
Fluctuating behavior maybe noted by staff or family, or documented in the medical record.
We also need to understand the definition of inattention.
Reduced ability to maintain attention to external stimuli and to appropriately shift attention
to new external stimuli.
Patient seems unaware or out of touch with the environment, dazed, fixated or darting
attention.
Disorganized thinking is evidenced by rambling, irrelevant and/or incoherent speech.
So as we move into the first item here, C1610A and C1610B we're asked to assess for acute
changes in mental status and find evidence of acute changes through a variety of methods
including our patient interactions, medical record, reports from family or caregivers,
and then staff reports as well.
Here is Section C1610A on the LTCH CARE Data Set.
We would code either 0, No, if we're unable to find evidence of any acute changes in mental
status from the patient's baseline.
Or we could code 1, Yes, if we find evidence of an acute change.
This coding is required for admissions, planned and unplanned discharges.
And then for C1610B, we also have the option of coding 0, No, if the abnormal behavior
did not fluctuate during the day, did not tend to come or go, or increase or decrease
in severity.
And we would code 1, yes, if the abnormal behavior fluctuated during the day and it
came and went, or increased or decreased with severity.
And here we're trying to answer, did the abnormal behavior fluctuate during the day, that is
tend to come and/or go, increase or decrease in severity?
And then C1610C, we're also asking here to make a distinction between attention and level
of consciousness.
Inattention is evidenced by patient clinician records and interactions, medical records,
reports from families and significant others, staff reports.
Another method that is used for identifying inattention quite simply is to have the patient
count backward from 20.
And if unsuccessful, they may not have a strong attention.
C1610C, we have the options of coding 0, No, if the patient remains focused and was not
easily distracted or having difficulty keeping track of what was said.
And we would code 1, Yes, if the patient had difficulty focusing or was easily distractible,
or was having difficulty keeping track of what was said.
And again, like the other sections for C1610D, disorganized thinking, we use the same steps
for assessment utilizing patient interview, medical record, reports from family and significant
others, and staff reports.
And for the coding of D, disorganized thinking, we also have code 0 for no if the patient's
thinking was organized and coherent.
Even if the answers were inaccurate or wrong.
And code 1, Yes, if the patient's thinking was disorganized or incoherent such as rambling
or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching
from subject to subject.
And C1610E1 and C1610E2 altered level of consciousness, we're utilizing the same methods for assessing,
the same steps for assessing this section as the ones prior, patient and clinician interactions,
medical record, reports from family and staff reports.
And here on the LTCH CARE Data Set we see altered level of conscious with the option
to code 0, No, if the patient was not alert.
And code, 1, Yes if the patient was alert.
This assessment is required on admission, planned and unplanned discharge.
C1610E2 is asking us to qualify the altered level of consciousness.
And we code 0, No, if the patient did not exhibit any of the following.
Vigilant hyper alert, such as the patient being easily startled to any sound or touch,
his or her eyes are wide open.
If they do not exhibit lethargy, drowsy and are easily arouse.
Patient repeatedly dozes off while you're asking questions.
It may be difficult to keep the patient awake for the interview.
The next item you would want to consider is stupor, difficult to arouse.
The patient is very difficult to arouse, and to keep aroused for the interview, requiring
shaking and/or repeated shouting.
Hopefully gently.
Then coma, unarousable, the patient can not be aroused despite shaking or shouting.
So in this scenario we would then code 1, Yes, if the patient did exhibit any of those items.
So we're coding, no, if they are not exhibiting any of those signs and symptoms.
And coding, yes, if they do.
So let's try some coding scenarios now for C1610D.
Mrs. B was admitted to the LTCH with a tracheostomy in place and was receiving invasive mechanical
ventilation.
There are no plans for active weaning due to a current respiratory infection.
Mrs. B is alert and oriented.
Mrs. B's thinking is organized and coherent.
She communicates effectively using a letterboard and by writing notes.
How would we code C1610D?
We have the options of coding 0, No.
Coding 1, Yes.
Entering a dash.
Or leaving the item blank.
We're trying to answer the question, was the patient's thinking disorganized or incoherent,
such as rambling or irrelevant conversation, or unclear or illogical flow.
So 100% of us said code 0, No.
And that is correct.
And so we code it this way because Mrs. B's thinking is organized and coherent.
She's alert and oriented and communicates effectively using her letterboard and by writing
notes.
The clinicians are able to determine this by using the identified communication strategies
and by observing the patient's interactions with others.
Additional sources to validate the patient's status during the 3-day assessment period
are the medical record, the family and staff, as mentioned for all of the sections.
So in summary, Section C has not changed.
Section C is utilized to determine if the patient has signs and symptoms of delirium.
The reason this section is so important is because sometimes delirium is unrecognized
and undocumented.
But we know that early recognition and treatment can result in improved outcomes for the patient.
Now we'll move on to Section H, Bladder And Bowel.
Our objectives for this section are to define Section H, Bladder and Bowel, explain the
intent and rationale of the section, discuss the coding instructions and required information,
and then apply those coding instructions to practice scenarios.
Section H is intended to gather bladder and bowel continence, because bladder and bowel
continence can have a number of negative of impacts on the patient, including increased
length of stay, skin breakdown, rashes and wound worsening
increased falls as the patient makes attempts
to get out of bed unassisted for the bathroom, and social embarrassment and isolation.
It can sometimes be addressed or minimized by treating the underlying condition.
So again, it's very important to address and recognize bladder and bowel incontinence.
There are some important definitions for Section H. Continence is the ability to voluntarily
release urine or stool in a commode, toilet or bedpan.
Incontinence is the involuntary passage of urine or stool.
Section H0350 on the LTCH CARE Data Set is where we have bladder continence.
We code one of the provided options on the admission and planned discharge assessments.
And our options are always continent, stress incontinence only, incontinent less than daily,
incontinent daily, always incontinent, no urine output, or not applicable.
To gather information for section H0350 we want to review the medical record including
flow sheets, nursing assessments, progress notes, HMPs, but also family input and caregiver
and staff information.
One reason that the flowsheets are so helpful is that we code according to the amount and
the number of episodes of incontinence that occur during the assessment period.
And that's typically found in our flowsheet documentation.
Code 0, Always continent if throughout the 3-day assessment period the patient was continent
of urine without any episodes of incontinence.
Code 1, stress incontinence only if during the 3-day assessment period the patient had
episodes of incontinence only associated with physical movement, or activity such as coughing,
sneezing, laughing, lifting heavy objects or exercise.
Code 2, incontinent less than daily, if during the 3-day assessment period the patient was
incontinent of urine once or twice.
Code 3, incontinent daily, if during the 3-day assessment period the patient was incontinent
of urine at least once daily.
Code 4, always incontinent if during the 3-day assessment period the patient had no continent
voids.
Code 5, no urine output, if during the 3-day assessment period the patient had no urine
output, such as in a patient with renal failure or chronic dialysis for the entire 3 days.
And Code 9, not applicable if during the 3-day assessment period the patient had an indwelling
bladder catheter, condom catheter, or ostomy for the entire 3 days.
We often get questions about stress incontinence and how this is defined and how it's applicable
in Section H. So stress incontinence really is referring to episodes of small amounts
of urine leakage only associated with physical movement or activity, such as I mentioned
coughing, sneezing, laughing, lifting objects or exercise.
And this is an important distinction, that it's a small amount of urine leakage.
And it's a result of one of these exercises.
Also incontinence is the same as leakage.
They're viewed one in the same for your assessment.
As mentioned, we have to get the documentation to determine the frequency.
And also if intermittent catheterization is used to drain the bladder, you code the incontinence
level based on the continence between the catheterizations.
So if the patient is otherwise continent, then you would code continent as such.
H0400 is for bowel continence.
It's applied only on admission.
H0400 is also assessed using the same steps for assessment, reviewing the medical record,
bowel incontinence flowsheets, nursing assessments and progress notes, history and physical,
interview with family and patients, and the direct care staff.
So for coding H0400 bowel continence, we want to code, 0, for always continent if during
the 3-day assessment period the patient was continent for all bowel movements without
any episode of incontinence.
We're coding, 1, Occasionally incontinent if during the 3-day assessment period the
patient was incontinent for a bowel movement, which includes incontinence for any amount
of stool at anytime.
Code 2, frequently incontinent, if during the 3-day assessment period the patient was
incontinent for bowel movements at least twice, but also had at least one continent bowel movement
And this includes incontinence of any amount of stool as well.
Code 3, always incontinent, if during the 3-day assessment period the patient was incontinent
for all bowel movements, and had no continent bowel movements during the period.
Code 9, not rated, if during the 3-day assessment period the patient had an ostomy or other
device, or the patient did not have have any bowel movements during the 3 days.
Any patient that doesn't have a bowel movement for 3 days should be evaluated for constipation.
Here are some coding tips for H0400, they address some of our stumbling blocks in the
LTCH environment.
Being continent has the to do with the ability to voluntarily release stool on a commode,
toilet or bedpan, or as a result of a planned bowel movement as part of a bowel program.
If the patient can not voluntarily control the passage of stool, which results in involuntary
passage of stool, then he or she is considered incontinent.
Patients who require assistance to maintain the passage of stool via artificial initiation,
like manual stimulation, or rectal suppositories or enemas would be considered continent of
their bowel, as long as the result of releasing the stool was in a commode, toilet or bed pan.
Bowel incontinence participated by loose stool or diarrhea from any cause including laxatives
would count as incontinence.
Let's try a coding scenario for H0350.
Here's a coding scenario for bladder continence.
Mrs. B has a history of stress incontinence.
During her 3-day assessment, she experienced a large amount of urine leakage daily.
How would we code H0350?
We really want to remember our definition of stress incontinence for this one.
So, A, we would Code 1, stress incontinence only.
B, code 2, incontinent less than daily.
Code 3, incontinent daily.
Or Code 4, always incontinent.
Okay.
It looks like all of our responses are in.
77% chose code 3, incontinent daily.
We'll review why this is the correct answer.
So in Mrs. B's case, she is incontinent daily because of large amounts of leakage.
And that's considered incontinent.
So if we were referring to her diagnosis of stress incontinence, it would be a small amount
of leakage.
Although she does have the history of stress incontinence, this is categorized by the small
amounts.
And it must be associated with a physical movement, or activity, or exercise.
So in Mrs. B's case, because it's large and not related to one of those activities, although
she has the diagnosis, it would not be considered stress incontinence and would rather be considered
incontinent daily.
So in summary, Section H has not changed and it gathers the urinary and bowel continence
details.
Patients with intermittent catheterizations should be coded based on their level of continence
between catheterizations.
And information can be gathered from the record, interviews, or patient's family and direct
caregivers for all of the items in the section.
Section J, Health Conditions, Falls.
So the objectives for the section are to define Section J, Health Conditions, explain the
intent and rationale or Section J, discuss coding instructions and required information
for the items.
And then apply the coding instructions to accurately code a practice scenario.
The intent of Section J is to collect falls since admission and any injury caused by the
fall.
However, only falls with major injury which are entered into Section J1900C are used in
the calculation of the quality measure Application of Percent of Residents Experiencing One or
More Falls with Major Injury is how it reads.
It's based on NQF#0674.
The rationale for collecting data in Section J1800 is that falls are a leading cause of
morbidity and mortality among LTCH patients.
The fear of falling can limit an individual's activity and negatively impact their quality
of life as well as their progress in the medical setting.
There's some very important definitions associated with Section J. A fall has a very specific
definition.
And it's defined by an unintentional change in position, coming to rest on the ground,
floor, or onto the next lower surface, for example onto the bed or chair, or a mat beside
the bed.
It may be witnessed, reported by the patient, or an observer, or identified when a patient
is found on the floor or the ground.
And it can not be the result of an overwhelming external force.
So for example, if one patient pushes another patient, we would not consider this a fall
in Section J. An intercepted fall occurs when the patient would have fallen if he or she
had not caught him or herself or had not been intercepted by another person.
And an intercepted fall is considered a fall in the LTCH setting.
The Centers for Medicare & Medicaid Services understand that challenging a patient's balance
and training him or her to recover from a loss of balance is an intentional therapeutic
intervention and does not consider anticipated losses of balance that occur during supervised
therapeutic interventions as intercepted falls.
We often hear from our therapists that they're challenging the patient.
And that in the setting for Section J would not be considered an intercepted fall.
There's some additional definitions that help us to sort through the terms of injury, major
injury and injury except major.
So injury related to a fall is any documented injury that occurred as a result or was recognized
within a short period of time, like a few hours, after the fall and attributed to the
fall.
So we know sometimes it's difficult to attribute the injury directly to the fall in the moments
right after.
Sometimes things will pop up in the next couple of hours or after assessment.
So that injury would be relatable in this section.
Major injury includes bone fractures, joint dislocations, closed head injuries with altered
consciousness and subdural hematomas.
An Injury except major include skin tears, abrasions, lacerations, superficial bruises,
hematomas and sprains, or any fall-related injury that cause the patient to complain
of pain.
To gather this information, you want to review the LTCH medical record, but also you can
utilize physician, nursing therapy, and nursing assistant notes, incident reports, fall logs,
whatever method you utilize in your environment to capture falls.
On the planned discharge, unplanned discharge, and expired assessments, you will be asked
to complete this question.
Has that patient had any falls since admission?
And then a follow-up question to J1900 asks us to document the number of falls by injury type.
So we do need to fill out each one of these boxes and code 0 None, or 1 for One, and 2
for Two or more.
We want to determine the number of falls that occurred since admission, and then record
their related level of injury.
Code each fall only one time.
So if a patient has multiple injuries in a single fall, you want to code the highest
level of injury.
So Section J1900A, we have some coding for each of the sections here.
So we have Code 0, None, if the patient had no injurious falls since admission.
Code 1 if the patient had one non-injurious fall since admission.
Or code 2 if the patient had two or more non-injurious falls since admission.
Similarly for J1900B, we would also want to code this section independently.
So we want to Code 0, None, if the patient had no injurious falls except major.
We want to Code 1, One, if the patient had one injurious falls except major since admission.
And then we want to Code 2, Two or more if the patient had two or more injurious
falls except major since admission.
And then finally, J1900C is where we're coding our major injuries.
So here if the patient had a major injurious fall -- had no major injurious falls since
admission we want to code 0, none.
We want to code 1, one, if the patient had one major injurious fall since admission.
And 2, for two or more injurious falls since admission.
Let's try a couple of coding scenarios for J1800.
Ms. K is transferred from the LTCH to the acute-care hospital for a radiology exam.
During the course of the exam Ms. K sustains a fall and fractures her right arm.
She is treated at the acute-care hospital and requires an overnight stay, but then subsequently
returns to the LTCH the following day.
How do we code J1800, has the patient had any falls since admission?
So we have code 0, No.
Code 1, one for Yes.
And then a dash if you think that that's appropriate.
So 100% of us said Code 1, Yes, which is great.
It means we understand program interruptions as well.
And the rationale for that is that since the patient returned to the LTCH from an acute care
hospital after a stay lasting less than 3 days, the patient was on a program interruption.
And therefore we would report it as just as if it had happened in our setting.
The information on the fall that occurred from the acute care hospital, provided that we're
made aware of it, and in this case that the injury is so significant that of course we
would be, would be captured on the planned discharge, unplanned discharge and expired
assessment when the patient is discharged from the LTCH.
This is an instance where both the fall in the LTCH and the acute hospital would have
to be recorded.
It would have to be recorded in both settings.
So here's another coding scenario for J1800 and J1900.
A patient reports to his nurse that while transfering to the bathroom he fell backward
and hit his head on the toilet.
The x-ray revealed a spinal fracture.
I don't know about you guys, but some of these are my worst nightmare.
(Laughter) So how do we want to code, has the patient had any falls since admission?
You can code 0 for No.
Code 1 for Yes.
Or entering a dash if we think that that is appropriate.
It looks like we're all finished.
So 92% of us said Code, 1, Yes.
And that is the correct answer.
So let's go through the rationale and why we would code yes in this scenario.
We have to wait a minute, because we have to answer the next one first.
So for J1900 using the same scenario, the number of falls since admission, how would
we code J1900A no injury, as one?
J1900B, injury except major as two, two or more?
Code J1900C as major injury, 1?
So 100% of us said C, J1900C, Major injury, one.
That is the correct answer.
And so just in case we were wondering how we got to that answer, here's a summary of
J1800 and J1900.
We would code J1800, any falls since admission as one, as we had indicated.
Our falls with no injury as 0, because although we had a fall, the fall was a major injury.
We would code falls with injury except major as 0, patient did not have any other falls
with anymore minor injuries.
And then falls with major injury as 1 because of the spinal fracture.
So in summary, Section J has not changed.
Section J for the LTCHs captures any falls and injuries from the time of admission, including
those which occurred during program interruptions.
Section J is completed on planned, unplanned and expired discharges.
Moving on to Section O, Special Treatments, Procedures and Programs, including Influenza Vaccination.
At the end of this section review you'll be able to identify the time period beginning
and end for the influenza season, and the influenza vaccination season.
You'll be able to distinguish the relationship between the influenza season and the influenza
vaccination season on the LTCH CARE Data Set.
And then apply the coding instructions to accurately code these data elements.
So the rationale for O0250 really centers around the fact that individuals, especially
older adults and those with health conditions are at increased risk for complications when
they are infected with influenza.
At an institution such as an LTCH, an Influenza A outbreak can lead to up to 60% of the population
falling ill, and 25 percent of those affected suffering severe complications.
Mortality results from influenza-associated illnesses such as pneumonia and patients that
are common in the LTCH environment with chronic or immunocompromised disease can be exacerbated
by influenza.
So let's first review the influenza season.
Beginning on July 1st of the current year, and then it ends June 30th of the following
year.
So using our current influenza season, 2017-2018 influenza season begins July 1 of 2017 and
ends on June 30 of 2018.
This should distinguish influenza from the influenza vaccination season, which begins
October 1st of the current year, or when the influenza vaccine becomes available, if you're
facility does not receive your vaccination by October 1st.
But it's whichever one comes first, and ends March 31st of the following year.
So for 2017-2018 our influenza vaccination season began on October 1st of 2017 and ends
on March 31st of 2018.
So although the vaccination season is defined specifically as we just reviewed, LTCHs should
document year-round, including when a patient has been vaccinated outside of the influenza
vaccination season.
If the influenza vaccination was administered to a patient for the current influenza season
at the time of, or prior to admission, then that information would be reflected on the
patient's Discharge Assessment.
For the quality measure, only the records of patients in the LTCH one or more days during
the influenza vaccination season, at least one day between October 1st and March 31st
are included in the calculation.
Here's how Section O appears on the LTCH CARE Data Set. It appears on admission, planned
discharge, unplanned discharge and expired assessment.
Section O asks for documentation of three aspects of the administration of the vaccine.
O0250A asks whether a vaccine for the current influenza season was administered in the facility.
O0250B asks for the date the patient received the vaccination, if it was administered in
the facility.
And O0250C gives the reason the patient did not receive the vaccination if it was not
received in the facility.
So to code section O0250A we have several options.
Code 0, No, if the patient did not receive the influenza vaccine in the facility during
this year's influenza vaccination season.
And then if that was the case, you would proceed to O0250C, to give the reason that it was
not received.
However, we would Code 1, Yes, if the patient received the influenza vaccine in the facility
during this year's influenza vaccination season.
And then we would go on to code O0250B and give the date of the vaccination.
To code O0250B, we enter the date that the vaccine was received by the patient in your
LTCH.
And it is important not to leave any boxes blank.
So just like the other sections that we've reviewed, you want to add a 0 into the box
if there's not another digit that should be placed there.
For example, October 6th of 2017 should be entered as 10-06-2017.
A full 8 character date is required.
And if the date is unknown, or the information is not available, you would need to use a
single dash in the first box.
For section O0250C, we have several coding options as well.
Here we would code 1, patient not in facility during the year's influenza vaccination season
if the patient was of course not in the facility during that time frame.
We would code 2, received outside of this, facility if the patient received an influenza
vaccination in another setting during this year's influenza vaccination season.
We code 3, Not eligible, if the patient has a medical contraindication if the influenza
vaccination was not received because of the contraindication or precautions.
This could include allergic reactions to eggs, or other vaccine components.
It can include a previous reaction, or a physician order not to immunize, history of Guillain-Barre
Syndrome, within six weeks of the previous influenza vaccination.
However the patient should be vaccinated if the contraindications or the precautions end
for some reason.
We also can code 4, offered and declined, if the patient, or responsible party, or legal
guardian has been informed of what is being offered and chooses not to accept the influenza
vaccination.
We can code 5, not offered, if the patient, or responsible party, or legal guardian was
not offered the influenza vaccine.
Code 6, inability to obtain vaccine due to a declared shortage if the influenza vaccine
was unavailable at the facility due to a declared vaccine shortage.
However the patient should be vaccinated once the facility receives the vaccine and the
annual supply of the inactivated influenza vaccine and the timing of its distribution
cannot be guaranteed in any year.
Code 9, none of the above, if none of the listed reasons describe why the influenza
vaccine was not administered.
This code is also used if the answer is unknown.
So let's do a practice scenario for coding O0250.
Mrs. J received the influenza vaccine in the LTCH during this year's influenza vaccination
season on October 2 of 2017.
How would you code O0250 and what is your rationale?
This is not a polling question.
So here we can go through O0250A.
So A would be coded as 1, Yes, because we know that she did receive the vaccination.
So O0250A would be coded as 1, Yes,
And then we would skip O0250C because there's no reason that she did not receive the vaccination.
She did receive the vaccination.
Let's try another one.
O0250 Coding Scenario 2 has Mrs. T receiving the influenza vaccination at her
doctor's office during the year's influenza vaccination season.
Her doctor provided documentation of Mrs. T's receipt of the vaccine to the LTCH to
place in Mrs. T's medical record.
He also provided documentation that Mrs. T was explained the benefits and risks of the
vaccine prior to administration.
How would you code O0250?
And what is your rationale?
If you can think through A, B and C. So in this scenario O0250A would be coded 0, No.
She did not receive the vaccination in the LTCH.
We would then code O0250B by skipping that section.
So it's not coded.
And O0250C would be coded as 2, received outside of this facility.
She did receive it at her doctor's office.
And it was during this year's influenza vaccination season.
We have another coding scenario for O0250.
Mr. N was offered the influenza vaccine during his LTCH hospitalization beginning in February
2017.
Mr. N refused the influenza vaccine, asserting it always gave him the flu when he received
it in the past.
There's something we've never heard before right.
(Laughter) How would you code O0250, and what is your rationale?
So in this coding scenario we would code O0250A as 0, No.
It was not received in the facility.
We would skip O0250B.
And then we would move on to O0250C.
And we would code it as 4, offered and declined.
We did make the offer.
He refused it.
We should have good documentation of those refusals as well.
So in summary, Section O is a very important section for our patients who are at serious
risk.
Patients that are infected with influenza are at a higher risk for complications and
it's more likely that they require a higher level of care and hospitalization.
CDC does recommend an annual influenza vaccination, especially for at-risk populations.
And that overall is a summary of all of the sections that we've reviewed today.
We went through Section C, H, J for Falls and O, Influenza Vaccination.
None of those have changed.
We did add one clarification to Section B to include the non-verbal communication.
So we want to make sure that we communicate what we have learned today, or realized today,
through Action Planning back at our facilities.
So take the time to review the intent, rationale, and the steps for assessment for all of the
sections with your teams.
You'll likely get a better outcome and better documentation if people understand these aspects.
Review the language clarification that was made in Section B and its implication, making
sure that everyone understands we can now account for non-verbal communication.
Review the key dates related to the influenza vaccination season, being that we're right
in the middle of it at this point.
It's very important that everyone is aware and offering vaccination to our patients.
And practice coding a variety of scenarios with the staff.
There are scenarios that are located in the QRP Manual if you're looking for some to go
through with your staff and help them to practice coding scenarios as well.
I have about a minute and a half.
We covered a lot of content.
I don't know if anyone has any questions at this point or if you're all ready for lunch.
It's okay you can ask them.
»» I have a question.
»» Could you please come to the microphone if you wouldn't mind.
»» Sheila Brady from Baptist Health Extended Care.
In item C1610B when talking about the abnormal behavior fluctuating during the day, is that
day considered a 24-hour period or just during daylight time?
»» Would anyone like to clarify that?
The question was, when we're referencing "day" for the fluctuating behavior, are we referencing
the daytime hours or the 24-hour day as a whole?
»» We'll pause for a moment.
Good question.
»» 24 hours.
»» That's confirmed it's a 24-hour period.
Great question.
Thank you for clarifying.
Any others?
Thank you for your time.
-------------------------------------------
4Com Foundation Community Lunch 2018 - Duration: 2:33.
So, here we are once again at the 4Com building, hosting our luncheon for the
Christchurch Angels. We've done several now and each time keeps on getting
stronger and stronger and we get a better response every time.
My name is Glenis Brown and I'm the coordinator for Christchurch Angels.
Christchurch Angels is the befriending service for people who are lonely and people who
are isolated because social isolation is such a major part of our elderly population
in particular.
We've had 17 clients come. Plus some of their volunteers have been able to bring
them and we've had a luncheon they've had an opportunity to chat to some of the
staff here, who have all been really friendly and welcoming to them. We've had music
we've been able to have a sing-along...
We've also played bingo which was great fun...
...next number out, is four and three, 43. Check 83. Big round of applause to the
ticket in the middle.
Winning yourself a luxury chocolate hamper right there.
As you can see, everyone's enjoying themselves having a great day. A lot of these people
they don't get out a lot you know they've only got themselves to entertain
themselves so it's always nice to host something like this where everyone can
get together and talk. It's been an absolutely great response from the staff
members. There's a selection of us from all departments all helping out
today, and they've really done 4Com proud.
It just makes more difference than you could even begin to think about to
somebody that's lonely to have that
level of interest. They'll think about and talk about it for weeks.
-------------------------------------------
We sqeezed a 15 HP Motor into a BOBBYCAR! | TOO MUCH POWER - 0-70km/h in 3 sec! - Duration: 4:33.
It's a lot of fun to ride this Bobbycar but I hate it if Mathis overtakes me
with his Puky scooter so we will give this thing some power
The Bobbycar is finished now, we build a 15 HP electric engine into it
It should go up to 80km/h
this is much too much power for this small car
I hope we will be able to overtake Mathis on his scooter
you can wath his video here
It didn't want to slow down
nothing has happened to me
Our bobbycar did brake a little bit
we are now going to the service station to see if they can help us
let's see what they say
Hey, we have a problem with our car
we wanted to ask if you can help us
what did you do - we just need some tools
we'll sure have that
that would be awesome
what kind of car is this?
this is our new car, it has 15 horsepower
we have to fix this
this really was I lot of fun! It was a good idea to give this thing a motor
the sound could be much better, that's why we added this sound generator
we did this together with CONRAD on their channel
you should really look at it
there also is a roomtoor of our workshop
we will be there more often in the future
check out the video, it turned out awesome!
you can find the link in the description
this Bobbycar just needed 3 seconds to go from 0 to 70 km/h
this is really fast - if you think, your car can beat us, let us know, we will do a race
if you don't want to miss this, don't forget to subscribe!
-------------------------------------------
Denise Breitburg STAR Seminar Habitat - Duration: 12:38.
>> Thank you very much and I apologize to those of you
that have heard all this before.
But for those of you that haven't I think you're going
to hear some of the same themes coming up and,
as somebody that's worked on fish for a long time,
I have to say that I was actually surprised
that we were able to detect as many effects of both watershed,
land use and shoreline type
on near shore fish assemblages as we did.
And you're going to see some of the same kinds
of things being repeated that we saw for water birds and for SAV.
The work that I'm going to be talking about was done --
A lot of the work was done
by a [inaudible] Matt Komiss [assumed spelling] who's working
for Fish and Wildlife now.
And I've got just one slide I'm going to show
of Rochelle [inaudible] who did work on [inaudible] vertebrates.
She would be great to have up here to give --
also to have a little fuller explanation
of the work that she did.
So this is kind of what you've seen before.
What we did is we looked at land cover.
They're including agriculture, native marsh -- I'm sorry.
Sorry. Agriculture.
Forest. Developed land.
And marshes, especially near shore.
And then we looked at right along the shore what kind
of structures were there,
whether it was rip rap [assumed spelling] bulkhead,
native marshes or beach.
We sampled in two ways.
Kind of traditional beach stains modified a little bit
so that they were much more quantitative then beach staining
normally would be.
And then with the help of Steve Giordano
from NCBO we also sampled with 200 foot long beach stains
so that we could do a really good job
of getting really high mobile fish.
These were deployed using a boat and we got everything from,
you know, big full sized red bass
to [inaudible] and everything.
As well as smaller things.
It was a really effective way of sampling.
What we did is our group did three years of sampling
in an essentially randomized block design.
So about 25 sub estuaries.
We sampled two sites of each shoreline type.
One with big nets and then in both cases we used small nets.
But then we also got together with a number of collaborators
who were really generous in sharing their data
who had looked at similar issues in the bay.
Rochelle, Donna Bilkovic from VIMS, Rich [inaudible]
and Tim Targett from Delaware.
Tim was a co-PI on this project as well.
Ryan King from the former project that you've heard about,
Jim Uphoff from DNR, Steve Giordano and David Bruce
from NCBO and John Jacobs from the Oxford lab.
And so among all of us we had data on 45 sub estuaries
within Chesapeake Bay.
Over 600 samples.
Lots and lots of individuals.
And by looking at this larger data set we were able
to pull apart a lot of relationships
that the individual studies were not able to.
And so basically what we did is we looked
at factor affecting the abundance
of basically just the 16 most abundant species
in our samples ranging from forage species like mummichogs
and anchovies and spot to some important fishery species
and the [inaudible] so croakers and striped bass and blue crabs.
So we had quite an array of species
that we had enough data to look at.
And we -- There were also differences
in the food available for fish in the different shorelines.
And so what Rochelle found is
in fact again benthic cray were more abundant along the marsh
and the beaches than along rip rap or bulkhead.
Higher biomass in the beaches and higher diversity
in marshes and beaches.
So food is more abundant in some of these habitats than others,
but then the other thing is the reason that body size
and how bottom oriented species are comes in to play is probably
because what happens whether you're putting in bulkhead
or rip rap you're essentially eliminating this very shallow
near shore habitat that essentially becomes a refuge
from larger bodied predators.
So the larger species get right up to shore
if you've got a bulkhead or rip rap reinforcing that shoreline.
And this is -- This sort of effect has been seen before
in some experimental work and sampling that Hines
and Gregory Ruiz did quite a few years ago.
But essentially the greater water depth allows access
to predators.
So the second take home message besides the fact
that different species like different kinds of shorelines is
that the proportion of the watershed land use comprised
of agriculture is negatively related to near shore abundances
of several important species of blue crab, spot and croaker.
And here are the data and it's pretty clear that as the percent
of cropland in the watershed goes up the abundances
of a number of species decline.
The abundances of these species, though,
is more of the species actually, though, are positively related
to the amount of wetland in the watershed.
So while 3 of the 16 species were negatively related
to agriculture, 9 out of the 16 were significantly positively
related to the amount of wetlands in the watershed.
And this is just an example showing the same 3 species
as before.
Again the more wetland, and this is within 100 meters
of the shoreline, then the more abundant the number
of these species are.
What we think is going on is
that the high cropland essentially results
in high nitrogen concentrations which do two things
because the fish aren't going to directly care
about the nitrogen, but it results in lower oxygen
and lower SAV which would normally provide refuges
for small and juvenile fish.
And the high cropland also probably displaces the near
shore wetlands.
And this just shows some of these relationships,
some of which you've already just seen, but the more cropland
in the watershed the more nitrogen in the water and --
But here also this is day time [inaudible] concentration
in fairly shallow water.
So even during the day you see a negative effect
on oxygen concentrations.
And it's enough of an effect
that it should be affecting fish.
So if we try to develop essentially a composite
relationship, the more cropland in the watershed, the less SAV
and wetlands you have and essentially the less fish.
However it's not universal.
There are some planktivores that increase
with increasing agriculture.
So it's important to realize, especially something
like menhaden, they're up in the water column
and essentially what happens probably is they're fertilizing
the system.
There's more food.
More menhaden.
Juvenile centrarchids are also planktivores and they seem
to at least somewhat benefit from the cropland.
We actually had a stronger effect of shoreline hardening,
a stronger negative effect of shoreline hardening,
than we did of cropland.
Again 9 out of the 16 species were negatively related
to the amount of hardened shoreline in the sub estuary.
So it was a much more universal response than agriculture.
And again just using the same three species, blue crab,
spot and croaker, as an example --
And again I'm just showing the univariate relationships,
but we developed some multivariate models
that really predicted a very high percentage
of the among sub estuary variation.
But the abundance of blue crab, spot, croaker
and quite a few other species declined as the amount
of shoreline hardening in a sub estuary increased.
And that shoreline hardening was again associated with the amount
of developed land in the watershed.
I wanted to just really quickly run through one very quick thing
because I think it's another important effect of rip rap --
shoreline hardening to think about.
We took a look at the use of hardened shoreline
by sea nettle polyps [inaudible] wintering stage of sea nettles
to see whether shoreline hardening might potentially
increase sea nettle populations on the local level.
And we did quite an elaborate
and numerous different kinds of field experiments.
But the bottom line is that, you know, orientation matters,
but if we put out granite in a bunch of different orientations
and we put out oyster shell, you know, on the bottom nearby,
the average density of sea nettle polyps we get
on those two habitats is just about the same.
2.7 per square centimeter and 2.4 per square centimeter.
And that is how many are remaining by the following May
if we put them out the previous summer.
So what winds up being important here is whether the rip rap is
extending deep enough in to the water
so that it is submerged even during extreme low tides
in the winter.
But if it is, it is used just as heavily as a recruitment site
for sea nettle polyps as their natural substrate in the bay
which would have been oyster shells.
And just very simple bottom line is
that what we've been seeing is that fish, shellfish
and jellyfish are all strongly affected by both land use
and shoreline hardening.
Thanks.
[ Applause ]
-------------------------------------------
Seat Leon ST 1.4 TSI 140 pk FR First Edition - Duration: 1:00.
For more infomation >> Seat Leon ST 1.4 TSI 140 pk FR First Edition - Duration: 1:00. -------------------------------------------
Diz Ağrısı: Yapmanız Gereken 4 Şey ve Kaçınılması Gereken Şeyler - Duration: 4:28.
For more infomation >> Diz Ağrısı: Yapmanız Gereken 4 Şey ve Kaçınılması Gereken Şeyler - Duration: 4:28. -------------------------------------------
POĞAÇA TARİFİ - MAYALI POĞAÇA NASIL YAPILIR? - Tuğba Turan Yıldız - Duration: 3:06.
650 gr flour 1 packet dry yeast 1 sweetspoon salt 1 egg 1 cup warm milk 1 cup warm water 1 water glass of olive oil Cheddar cheese
650 gr flour 1 packet dry yeast 1 sweetspoon salt 1 egg 1 cup warm milk 1 cup warm water 1 water glass of olive oil Cheddar cheese
650 gr flour 1 packet dry yeast 1 sweetspoon salt 1 egg 1 cup warm milk 1 cup warm water 1 water glass of olive oil Cheddar cheese
650 gr flour 1 packet dry yeast 1 sweetspoon salt 1 egg 1 cup warm milk 1 cup warm water 1 water glass of olive oil Cheddar cheese
1 sweetspoon salt
1 packet dry yeast
1 water glass of olive oil
1 cup warm milk
1 cup warm water
1 egg
We wait for 1 hour to blanch over and ferment
We wait for 10 more minutes to ferment
Bake for 20 minutes in a preheated 180 degree oven
-------------------------------------------
[칼럼]폴크스바겐 퇴출 1년, 한국 소비자 '호갱' 아니다[dailycar kr love] - Duration: 4:52. For more infomation >> [칼럼]폴크스바겐 퇴출 1년, 한국 소비자 '호갱' 아니다[dailycar kr love] - Duration: 4:52. -------------------------------------------
Fifth Harmony's Ally Brooke is Selena AND J-Lo | Lip Sync Battle - Duration: 0:54.
(lip-syncing) ♪ Ay ay ay, como me duele ♪
(upbeat bass)
♪ Let me introduce you to my party people ♪
♪ In the club, huh, huh, huh, ♪
♪ If you go hard you gotta get on the floor ♪
- Selena is my favorite entertainer of all time,
and also J-Lo has inspired me tremendously, as an artist.
She's so phenomenal and I thought
I wanna honor my two incredible Latinas.
(applause)
- [Announcer] New Lip Sync Battle,
Thursday at 10 on Paramount Network.
-------------------------------------------
Focused Review of Sections B, C, H, J, and O (Influenza) - Duration: 58:24.»» We'll spend the next hour reviewing Sections B, C, H, J and O including influenza.
And again, as in all the other presentations, this is a list of the acronyms that we'll
be using.
In the presentation, we will identify and explain the intent of each of the sections
and discuss the coding instructions and required information for Section B, Hearing, Speech
and Vision.
Section C, Cognitive Patterns.
Section H, Bladder and Bowel.
Section J, Health Conditions, Falls.
Section O, Special Treatments, Procedures and Programs, Influenza Vaccination.
And then we'll do some practice coding for these sections.
At the end of the presentation, you should be able to demonstrate a working knowledge
of each of these sections as well as state the intent of them, and then apply your coding
instructions to accurately code practice scenarios.
So first we'll look at Section B, Hearing, Speech, and Vision.
Specifically for Section B, our objectives today will be to describe the intent of the
section, explain the revisions to item BB0800, and use the guidance to accurately code our
practice questions.
The intent of Section B is to document the patient's ability to understand and communicate
with others.
This is accomplished by collecting data in three sections.
B0100, comatose.
BB0700, expression of ideas and wants.
BB0800, understanding verbal content.
Section B is intended to document the patient's ability to understand and communicate with
others in his or her primary language whether in speech, writing, sign language, gestures
or a combination of these.
It can be challenging to differentiate between these sections.
And data needs to be collected and reported for each.
In this section we'll go into more description of the sections and provide some examples
to help us with coding Section B. So we'll start with some clarifications.
Between v3.00 and v.4.00 of the LTCH CARE Data Set there are no changes with the first
two items B0100, comatose and BB0700, expression of ideas and wants.
For Section BB0800, a clarification has been provided with the addition of understanding
non-verbal content as opposed to only verbal.
This is of course tremendously helpful with our patient populations because we have so
many adaptive devices and methods for communication with our patients.
And this language now allows us to capture those.
While there are no changes made for B0100, comatose, we'll offer a new coding tip and
an example.
This scenario applies to an admission and planned Discharge Assessment and the reason
for the data collection is because patients who are in a coma or a persistent vegetative
state are clearly at increased risk for mobility complications as well as others.
So for B0100, we will use the code 1, Yes, for a diagnosis of coma or persistent vegetative
state, which is documented in the patient's medical record.
Review the medical record to determine whether a diagnosis of coma or persistent vegetative
state has been documented by a physician, nurse practitioner, physician assistant, or
clinical nurse specialist as allowable under your state laws.
You would code 0, No, if a diagnosis of coma or persistent vegetative state is not present
on admission or discharge.
We have some other common diagnoses that have similar symptoms but are not the same as coma
or persistent vegetative state, such as some of the progressive muscular neurological disorders.
So it's very important that we have it specifically documented as coma or persistent vegetative
state in the medical record.
So here's a coding scenario for B0100.
Mrs. M was admitted to the LTCH and is non-communicative and often sleeps.
Mrs. M's medical record includes a diagnosis of Alzheimer's disease.
Mrs. M's medical record does not include a diagnosis of coma or persistent vegetative state.
So how should we code B0100?
You'll code 0 for no?
And code 1 for yes?
Just a few more responses.
So 95% of us chose code 0, No.
And this is of course the correct answer.
We code no if a diagnosis of coma or persistent vegetative state is not present at the time
of admission or discharge.
And here we offer the rationale for how we coded this coding scenario.
Because there is no documentation in the medical record that states Mrs. M's diagnosis includes
coma or persistent vegetative state, No 0, is the most appropriate response.
The next section we'll review is BB0700, expression of ideas and wants.
This is completed on admission and planned Discharge Assessments.
And this is what it appears to look like on the LTCH CARE Data Set.
So let's try a coding scenario for BB0700.
Mr. B had a stroke several weeks ago and has a diagnosis of expressive aphasia.
The certified nursing assistant asks Mr. B if he wants help with bathing.
He looks at the certified nursing assistant and smiles, but does not respond verbally.
The certified nursing assistant reports to the nurse that she has not been able to determine
Mr. B's preference and needs help with his needs with any of his activities of daily
living since he was admitted the day before.
The nurse interacts with Mr. B and determines that he rarely expresses himself.
The nurse plans to collaborate with the speech language pathologist and other team members
and Mr. B to increase Mr. B's ability to express himself.
How would you code BB0700?
And our choices for BB0700 include coding 4, expresses complex messages without difficulty
and with speech that is clear and easy to understand.
Code 3, exhibits some difficulty with expressing needs and ideas or speech is not clear.
Code 2, frequently exhibits difficulty with expressing needs and ideas.
Or code 1, rarely/never expresses self or speech and is very difficult to understand.
Okay. So let's see how we did.
96% of you chose D, which is code 1 rarely/never expresses self or speech and is very difficult
to understand.
And that is of course the correct answer.
And the reason that we would choose this in the scenario is that due to Mr. B's expressive
aphasia.
He's unable to verbally express his needs.
That was indicated by both the CNA as well as the nurse.
Okay.
So BB0800 is our next section, understanding verbal, and now in addition non-verbal content.
This section is completed for admission and planned discharge as well.
As mentioned, any inability to understand a person-to-person communication can impact
our patient's well being including their association with other people, and their ability to follow
their health and safety instructions.
So here's a coding scenario for BB0800.
Mr. T sustained an acquired brain injury and is on an invasive mechanical ventilator.
Mr. T uses an electronic communication device to respond to staff and family questions.
Staff members report that he only understands basic conversation.
The staff needs to simplify all communication for him to understand what is being asked.
The family reports that simple and short messages are necessary during their conversation to
elicit accurate responses.
How would we code BB0800 in this scenario?
And our options are coding 4, Understands.
Code 3, Usually understands.
Code 2, Sometimes understands.
Or Code 1, Rarely/never understands.
So on this one we had 60% choose B, Usually understands.
And 36% choose C, Code 2, Sometimes understands.
So our correct answer is, C, Sometimes understands.
So let's go through our rationale for why we would pick Code 2.
In this situation, Mr. T uses his electronic device to indicate his understanding of only
basic conversations or simple direct phrases.
He's really understanding only the most basic conversations and direct phrases that are
directed to him.
Okay.
Here's another coding scenario for BB0800.
Mrs. K is recovering from the surgical removal of a cancerous brain tumor and has severe
hearing loss and some cognitive limitations.
The staff, patient, and family use an electronic device to communicate with her.
Staff members and family reports that Mrs. K on a few occasions required visual cues
to understand what is typed into her electronic device in order for her to respond accurately
to questions.
Mrs. K can understand most conversations with the use of her electronic device.
How would you code BB0800?
And for this we should choose from Code 4, Understands.
Code 3, Usually understands.
Code 2, Sometimes understands.
And code 1, Rarely/never understands.
Okay.
It looks like everybody has made a selection.
So 92% chose the correct answer which is code 3, usually understands.
So let's go through our reasoning for that selection.
3, usually understands.
In this scenario the patient understands most conversations but misses some part or some
intent of the message and requires some cues at times.
Mrs. K and her family use the electronic device to communicate and she's understanding most
of the communication with some cues, which makes 3, usually understands, the most appropriate
selection for her scenario.
So just summarizing Section B. Section B has not changed.
There does exist one clarification for BB0800 to include non-verbal content in addition
to verbal content.
But otherwise the section is unchanged.
Next section will be Section C, Cognitive Patterns.
So in this section we're going to define Section C and explain its intent and rationale.
We'll discuss coding instructions and required information for the items.
And we'll apply the coding instructions to accurately code practice scenarios.
Section C is intended to determine if a patient has the signs and symptoms of delirium using
the standardized Confusion Assessment Method or CAM.
The section on the LTCH CARE Data Set has a shortened version of the CAM to guide the
user to complete all requirements.
It includes A-E for completion with yes/no responses required for each.
There are some subtleties to be aware of in Section C. Delirium is often misdiagnosed
as dementia, or it can be.
However patients who truly have dementia can also experience delirium.
A recent deterioration in a cognitive function of a patient may indicate delirium, which
may be reversible if detected and treated.
Delirium can be the symptom of an acute treatable illness such as the case of a urinary tract
infection or an adverse reaction to medication.
Therefore detecting delirium in a timely manner can help clinicians determine acute changes
in condition that can then be treated by eliminating the source.
It's important to understand the definitions in Section C. Delirium is defined as a mental
disturbance characterized by new or acutely worsened confusion, disorganized expression
of thoughts, change in level of consciousness, or hallucinations.
Fluctuation is defined as the behavior that tends to come and go and/or increase or decrease
in severity.
The behavior may fluctuate over the course of an interview, discussion, or the assessment
period.
Fluctuating behavior maybe noted by staff or family, or documented in the medical record.
We also need to understand the definition of inattention.
Reduced ability to maintain attention to external stimuli and to appropriately shift attention
to new external stimuli.
Patient seems unaware or out of touch with the environment, dazed, fixated or darting
attention.
Disorganized thinking is evidenced by rambling, irrelevant and/or incoherent speech.
So as we move into the first item here, C1610A and C1610B we're asked to assess for acute
changes in mental status and find evidence of acute changes through a variety of methods
including our patient interactions, medical record, reports from family or caregivers,
and then staff reports as well.
Here is Section C1610A on the LTCH CARE Data Set.
We would code either 0, No, if we're unable to find evidence of any acute changes in mental
status from the patient's baseline.
Or we could code 1, Yes, if we find evidence of an acute change.
This coding is required for admissions, planned and unplanned discharges.
And then for C1610B, we also have the option of coding 0, No, if the abnormal behavior
did not fluctuate during the day, did not tend to come or go, or increase or decrease
in severity.
And we would code 1, yes, if the abnormal behavior fluctuated during the day and it
came and went, or increased or decreased with severity.
And here we're trying to answer, did the abnormal behavior fluctuate during the day, that is
tend to come and/or go, increase or decrease in severity?
And then C1610C, we're also asking here to make a distinction between attention and level
of consciousness.
Inattention is evidenced by patient clinician records and interactions, medical records,
reports from families and significant others, staff reports.
Another method that is used for identifying inattention quite simply is to have the patient
count backward from 20.
And if unsuccessful, they may not have a strong attention.
C1610C, we have the options of coding 0, No, if the patient remains focused and was not
easily distracted or having difficulty keeping track of what was said.
And we would code 1, Yes, if the patient had difficulty focusing or was easily distractible,
or was having difficulty keeping track of what was said.
And again, like the other sections for C1610D, disorganized thinking, we use the same steps
for assessment utilizing patient interview, medical record, reports from family and significant
others, and staff reports.
And for the coding of D, disorganized thinking, we also have code 0 for no if the patient's
thinking was organized and coherent.
Even if the answers were inaccurate or wrong.
And code 1, Yes, if the patient's thinking was disorganized or incoherent such as rambling
or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching
from subject to subject.
And C1610E1 and C1610E2 altered level of consciousness, we're utilizing the same methods for assessing,
the same steps for assessing this section as the ones prior, patient and clinician interactions,
medical record, reports from family and staff reports.
And here on the LTCH CARE Data Set we see altered level of conscious with the option
to code 0, No, if the patient was not alert.
And code, 1, Yes if the patient was alert.
This assessment is required on admission, planned and unplanned discharge.
C1610E2 is asking us to qualify the altered level of consciousness.
And we code 0, No, if the patient did not exhibit any of the following.
Vigilant hyper alert, such as the patient being easily startled to any sound or touch,
his or her eyes are wide open.
If they do not exhibit lethargy, drowsy and are easily arouse.
Patient repeatedly dozes off while you're asking questions.
It may be difficult to keep the patient awake for the interview.
The next item you would want to consider is stupor, difficult to arouse.
The patient is very difficult to arouse, and to keep aroused for the interview, requiring
shaking and/or repeated shouting.
Hopefully gently.
Then coma, unarousable, the patient can not be aroused despite shaking or shouting.
So in this scenario we would then code 1, Yes, if the patient did exhibit any of those items.
So we're coding, no, if they are not exhibiting any of those signs and symptoms.
And coding, yes, if they do.
So let's try some coding scenarios now for C1610D.
Mrs. B was admitted to the LTCH with a tracheostomy in place and was receiving invasive mechanical
ventilation.
There are no plans for active weaning due to a current respiratory infection.
Mrs. B is alert and oriented.
Mrs. B's thinking is organized and coherent.
She communicates effectively using a letterboard and by writing notes.
How would we code C1610D?
We have the options of coding 0, No.
Coding 1, Yes.
Entering a dash.
Or leaving the item blank.
We're trying to answer the question, was the patient's thinking disorganized or incoherent,
such as rambling or irrelevant conversation, or unclear or illogical flow.
So 100% of us said code 0, No.
And that is correct.
And so we code it this way because Mrs. B's thinking is organized and coherent.
She's alert and oriented and communicates effectively using her letterboard and by writing
notes.
The clinicians are able to determine this by using the identified communication strategies
and by observing the patient's interactions with others.
Additional sources to validate the patient's status during the 3-day assessment period
are the medical record, the family and staff, as mentioned for all of the sections.
So in summary, Section C has not changed.
Section C is utilized to determine if the patient has signs and symptoms of delirium.
The reason this section is so important is because sometimes delirium is unrecognized
and undocumented.
But we know that early recognition and treatment can result in improved outcomes for the patient.
Now we'll move on to Section H, Bladder And Bowel.
Our objectives for this section are to define Section H, Bladder and Bowel, explain the
intent and rationale of the section, discuss the coding instructions and required information,
and then apply those coding instructions to practice scenarios.
Section H is intended to gather bladder and bowel continence, because bladder and bowel
continence can have a number of negative of impacts on the patient, including increased
length of stay, skin breakdown, rashes and wound worsening
increased falls as the patient makes attempts
to get out of bed unassisted for the bathroom, and social embarrassment and isolation.
It can sometimes be addressed or minimized by treating the underlying condition.
So again, it's very important to address and recognize bladder and bowel incontinence.
There are some important definitions for Section H. Continence is the ability to voluntarily
release urine or stool in a commode, toilet or bedpan.
Incontinence is the involuntary passage of urine or stool.
Section H0350 on the LTCH CARE Data Set is where we have bladder continence.
We code one of the provided options on the admission and planned discharge assessments.
And our options are always continent, stress incontinence only, incontinent less than daily,
incontinent daily, always incontinent, no urine output, or not applicable.
To gather information for section H0350 we want to review the medical record including
flow sheets, nursing assessments, progress notes, HMPs, but also family input and caregiver
and staff information.
One reason that the flowsheets are so helpful is that we code according to the amount and
the number of episodes of incontinence that occur during the assessment period.
And that's typically found in our flowsheet documentation.
Code 0, Always continent if throughout the 3-day assessment period the patient was continent
of urine without any episodes of incontinence.
Code 1, stress incontinence only if during the 3-day assessment period the patient had
episodes of incontinence only associated with physical movement, or activity such as coughing,
sneezing, laughing, lifting heavy objects or exercise.
Code 2, incontinent less than daily, if during the 3-day assessment period the patient was
incontinent of urine once or twice.
Code 3, incontinent daily, if during the 3-day assessment period the patient was incontinent
of urine at least once daily.
Code 4, always incontinent if during the 3-day assessment period the patient had no continent
voids.
Code 5, no urine output, if during the 3-day assessment period the patient had no urine
output, such as in a patient with renal failure or chronic dialysis for the entire 3 days.
And Code 9, not applicable if during the 3-day assessment period the patient had an indwelling
bladder catheter, condom catheter, or ostomy for the entire 3 days.
We often get questions about stress incontinence and how this is defined and how it's applicable
in Section H. So stress incontinence really is referring to episodes of small amounts
of urine leakage only associated with physical movement or activity, such as I mentioned
coughing, sneezing, laughing, lifting objects or exercise.
And this is an important distinction, that it's a small amount of urine leakage.
And it's a result of one of these exercises.
Also incontinence is the same as leakage.
They're viewed one in the same for your assessment.
As mentioned, we have to get the documentation to determine the frequency.
And also if intermittent catheterization is used to drain the bladder, you code the incontinence
level based on the continence between the catheterizations.
So if the patient is otherwise continent, then you would code continent as such.
H0400 is for bowel continence.
It's applied only on admission.
H0400 is also assessed using the same steps for assessment, reviewing the medical record,
bowel incontinence flowsheets, nursing assessments and progress notes, history and physical,
interview with family and patients, and the direct care staff.
So for coding H0400 bowel continence, we want to code, 0, for always continent if during
the 3-day assessment period the patient was continent for all bowel movements without
any episode of incontinence.
We're coding, 1, Occasionally incontinent if during the 3-day assessment period the
patient was incontinent for a bowel movement, which includes incontinence for any amount
of stool at anytime.
Code 2, frequently incontinent, if during the 3-day assessment period the patient was
incontinent for bowel movements at least twice, but also had at least one continent bowel movement
And this includes incontinence of any amount of stool as well.
Code 3, always incontinent, if during the 3-day assessment period the patient was incontinent
for all bowel movements, and had no continent bowel movements during the period.
Code 9, not rated, if during the 3-day assessment period the patient had an ostomy or other
device, or the patient did not have have any bowel movements during the 3 days.
Any patient that doesn't have a bowel movement for 3 days should be evaluated for constipation.
Here are some coding tips for H0400, they address some of our stumbling blocks in the
LTCH environment.
Being continent has the to do with the ability to voluntarily release stool on a commode,
toilet or bedpan, or as a result of a planned bowel movement as part of a bowel program.
If the patient can not voluntarily control the passage of stool, which results in involuntary
passage of stool, then he or she is considered incontinent.
Patients who require assistance to maintain the passage of stool via artificial initiation,
like manual stimulation, or rectal suppositories or enemas would be considered continent of
their bowel, as long as the result of releasing the stool was in a commode, toilet or bed pan.
Bowel incontinence participated by loose stool or diarrhea from any cause including laxatives
would count as incontinence.
Let's try a coding scenario for H0350.
Here's a coding scenario for bladder continence.
Mrs. B has a history of stress incontinence.
During her 3-day assessment, she experienced a large amount of urine leakage daily.
How would we code H0350?
We really want to remember our definition of stress incontinence for this one.
So, A, we would Code 1, stress incontinence only.
B, code 2, incontinent less than daily.
Code 3, incontinent daily.
Or Code 4, always incontinent.
Okay.
It looks like all of our responses are in.
77% chose code 3, incontinent daily.
We'll review why this is the correct answer.
So in Mrs. B's case, she is incontinent daily because of large amounts of leakage.
And that's considered incontinent.
So if we were referring to her diagnosis of stress incontinence, it would be a small amount
of leakage.
Although she does have the history of stress incontinence, this is categorized by the small
amounts.
And it must be associated with a physical movement, or activity, or exercise.
So in Mrs. B's case, because it's large and not related to one of those activities, although
she has the diagnosis, it would not be considered stress incontinence and would rather be considered
incontinent daily.
So in summary, Section H has not changed and it gathers the urinary and bowel continence
details.
Patients with intermittent catheterizations should be coded based on their level of continence
between catheterizations.
And information can be gathered from the record, interviews, or patient's family and direct
caregivers for all of the items in the section.
Section J, Health Conditions, Falls.
So the objectives for the section are to define Section J, Health Conditions, explain the
intent and rationale or Section J, discuss coding instructions and required information
for the items.
And then apply the coding instructions to accurately code a practice scenario.
The intent of Section J is to collect falls since admission and any injury caused by the
fall.
However, only falls with major injury which are entered into Section J1900C are used in
the calculation of the quality measure Application of Percent of Residents Experiencing One or
More Falls with Major Injury is how it reads.
It's based on NQF#0674.
The rationale for collecting data in Section J1800 is that falls are a leading cause of
morbidity and mortality among LTCH patients.
The fear of falling can limit an individual's activity and negatively impact their quality
of life as well as their progress in the medical setting.
There's some very important definitions associated with Section J. A fall has a very specific
definition.
And it's defined by an unintentional change in position, coming to rest on the ground,
floor, or onto the next lower surface, for example onto the bed or chair, or a mat beside
the bed.
It may be witnessed, reported by the patient, or an observer, or identified when a patient
is found on the floor or the ground.
And it can not be the result of an overwhelming external force.
So for example, if one patient pushes another patient, we would not consider this a fall
in Section J. An intercepted fall occurs when the patient would have fallen if he or she
had not caught him or herself or had not been intercepted by another person.
And an intercepted fall is considered a fall in the LTCH setting.
The Centers for Medicare & Medicaid Services understand that challenging a patient's balance
and training him or her to recover from a loss of balance is an intentional therapeutic
intervention and does not consider anticipated losses of balance that occur during supervised
therapeutic interventions as intercepted falls.
We often hear from our therapists that they're challenging the patient.
And that in the setting for Section J would not be considered an intercepted fall.
There's some additional definitions that help us to sort through the terms of injury, major
injury and injury except major.
So injury related to a fall is any documented injury that occurred as a result or was recognized
within a short period of time, like a few hours, after the fall and attributed to the
fall.
So we know sometimes it's difficult to attribute the injury directly to the fall in the moments
right after.
Sometimes things will pop up in the next couple of hours or after assessment.
So that injury would be relatable in this section.
Major injury includes bone fractures, joint dislocations, closed head injuries with altered
consciousness and subdural hematomas.
An Injury except major include skin tears, abrasions, lacerations, superficial bruises,
hematomas and sprains, or any fall-related injury that cause the patient to complain
of pain.
To gather this information, you want to review the LTCH medical record, but also you can
utilize physician, nursing therapy, and nursing assistant notes, incident reports, fall logs,
whatever method you utilize in your environment to capture falls.
On the planned discharge, unplanned discharge, and expired assessments, you will be asked
to complete this question.
Has that patient had any falls since admission?
And then a follow-up question to J1900 asks us to document the number of falls by injury type.
So we do need to fill out each one of these boxes and code 0 None, or 1 for One, and 2
for Two or more.
We want to determine the number of falls that occurred since admission, and then record
their related level of injury.
Code each fall only one time.
So if a patient has multiple injuries in a single fall, you want to code the highest
level of injury.
So Section J1900A, we have some coding for each of the sections here.
So we have Code 0, None, if the patient had no injurious falls since admission.
Code 1 if the patient had one non-injurious fall since admission.
Or code 2 if the patient had two or more non-injurious falls since admission.
Similarly for J1900B, we would also want to code this section independently.
So we want to Code 0, None, if the patient had no injurious falls except major.
We want to Code 1, One, if the patient had one injurious falls except major since admission.
And then we want to Code 2, Two or more if the patient had two or more injurious
falls except major since admission.
And then finally, J1900C is where we're coding our major injuries.
So here if the patient had a major injurious fall -- had no major injurious falls since
admission we want to code 0, none.
We want to code 1, one, if the patient had one major injurious fall since admission.
And 2, for two or more injurious falls since admission.
Let's try a couple of coding scenarios for J1800.
Ms. K is transferred from the LTCH to the acute-care hospital for a radiology exam.
During the course of the exam Ms. K sustains a fall and fractures her right arm.
She is treated at the acute-care hospital and requires an overnight stay, but then subsequently
returns to the LTCH the following day.
How do we code J1800, has the patient had any falls since admission?
So we have code 0, No.
Code 1, one for Yes.
And then a dash if you think that that's appropriate.
So 100% of us said Code 1, Yes, which is great.
It means we understand program interruptions as well.
And the rationale for that is that since the patient returned to the LTCH from an acute care
hospital after a stay lasting less than 3 days, the patient was on a program interruption.
And therefore we would report it as just as if it had happened in our setting.
The information on the fall that occurred from the acute care hospital, provided that we're
made aware of it, and in this case that the injury is so significant that of course we
would be, would be captured on the planned discharge, unplanned discharge and expired
assessment when the patient is discharged from the LTCH.
This is an instance where both the fall in the LTCH and the acute hospital would have
to be recorded.
It would have to be recorded in both settings.
So here's another coding scenario for J1800 and J1900.
A patient reports to his nurse that while transfering to the bathroom he fell backward
and hit his head on the toilet.
The x-ray revealed a spinal fracture.
I don't know about you guys, but some of these are my worst nightmare.
(Laughter) So how do we want to code, has the patient had any falls since admission?
You can code 0 for No.
Code 1 for Yes.
Or entering a dash if we think that that is appropriate.
It looks like we're all finished.
So 92% of us said Code, 1, Yes.
And that is the correct answer.
So let's go through the rationale and why we would code yes in this scenario.
We have to wait a minute, because we have to answer the next one first.
So for J1900 using the same scenario, the number of falls since admission, how would
we code J1900A no injury, as one?
J1900B, injury except major as two, two or more?
Code J1900C as major injury, 1?
So 100% of us said C, J1900C, Major injury, one.
That is the correct answer.
And so just in case we were wondering how we got to that answer, here's a summary of
J1800 and J1900.
We would code J1800, any falls since admission as one, as we had indicated.
Our falls with no injury as 0, because although we had a fall, the fall was a major injury.
We would code falls with injury except major as 0, patient did not have any other falls
with anymore minor injuries.
And then falls with major injury as 1 because of the spinal fracture.
So in summary, Section J has not changed.
Section J for the LTCHs captures any falls and injuries from the time of admission, including
those which occurred during program interruptions.
Section J is completed on planned, unplanned and expired discharges.
Moving on to Section O, Special Treatments, Procedures and Programs, including Influenza Vaccination.
At the end of this section review you'll be able to identify the time period beginning
and end for the influenza season, and the influenza vaccination season.
You'll be able to distinguish the relationship between the influenza season and the influenza
vaccination season on the LTCH CARE Data Set.
And then apply the coding instructions to accurately code these data elements.
So the rationale for O0250 really centers around the fact that individuals, especially
older adults and those with health conditions are at increased risk for complications when
they are infected with influenza.
At an institution such as an LTCH, an Influenza A outbreak can lead to up to 60% of the population
falling ill, and 25 percent of those affected suffering severe complications.
Mortality results from influenza-associated illnesses such as pneumonia and patients that
are common in the LTCH environment with chronic or immunocompromised disease can be exacerbated
by influenza.
So let's first review the influenza season.
Beginning on July 1st of the current year, and then it ends June 30th of the following
year.
So using our current influenza season, 2017-2018 influenza season begins July 1 of 2017 and
ends on June 30 of 2018.
This should distinguish influenza from the influenza vaccination season, which begins
October 1st of the current year, or when the influenza vaccine becomes available, if you're
facility does not receive your vaccination by October 1st.
But it's whichever one comes first, and ends March 31st of the following year.
So for 2017-2018 our influenza vaccination season began on October 1st of 2017 and ends
on March 31st of 2018.
So although the vaccination season is defined specifically as we just reviewed, LTCHs should
document year-round, including when a patient has been vaccinated outside of the influenza
vaccination season.
If the influenza vaccination was administered to a patient for the current influenza season
at the time of, or prior to admission, then that information would be reflected on the
patient's Discharge Assessment.
For the quality measure, only the records of patients in the LTCH one or more days during
the influenza vaccination season, at least one day between October 1st and March 31st
are included in the calculation.
Here's how Section O appears on the LTCH CARE Data Set. It appears on admission, planned
discharge, unplanned discharge and expired assessment.
Section O asks for documentation of three aspects of the administration of the vaccine.
O0250A asks whether a vaccine for the current influenza season was administered in the facility.
O0250B asks for the date the patient received the vaccination, if it was administered in
the facility.
And O0250C gives the reason the patient did not receive the vaccination if it was not
received in the facility.
So to code section O0250A we have several options.
Code 0, No, if the patient did not receive the influenza vaccine in the facility during
this year's influenza vaccination season.
And then if that was the case, you would proceed to O0250C, to give the reason that it was
not received.
However, we would Code 1, Yes, if the patient received the influenza vaccine in the facility
during this year's influenza vaccination season.
And then we would go on to code O0250B and give the date of the vaccination.
To code O0250B, we enter the date that the vaccine was received by the patient in your
LTCH.
And it is important not to leave any boxes blank.
So just like the other sections that we've reviewed, you want to add a 0 into the box
if there's not another digit that should be placed there.
For example, October 6th of 2017 should be entered as 10-06-2017.
A full 8 character date is required.
And if the date is unknown, or the information is not available, you would need to use a
single dash in the first box.
For section O0250C, we have several coding options as well.
Here we would code 1, patient not in facility during the year's influenza vaccination season
if the patient was of course not in the facility during that time frame.
We would code 2, received outside of this, facility if the patient received an influenza
vaccination in another setting during this year's influenza vaccination season.
We code 3, Not eligible, if the patient has a medical contraindication if the influenza
vaccination was not received because of the contraindication or precautions.
This could include allergic reactions to eggs, or other vaccine components.
It can include a previous reaction, or a physician order not to immunize, history of Guillain-Barre
Syndrome, within six weeks of the previous influenza vaccination.
However the patient should be vaccinated if the contraindications or the precautions end
for some reason.
We also can code 4, offered and declined, if the patient, or responsible party, or legal
guardian has been informed of what is being offered and chooses not to accept the influenza
vaccination.
We can code 5, not offered, if the patient, or responsible party, or legal guardian was
not offered the influenza vaccine.
Code 6, inability to obtain vaccine due to a declared shortage if the influenza vaccine
was unavailable at the facility due to a declared vaccine shortage.
However the patient should be vaccinated once the facility receives the vaccine and the
annual supply of the inactivated influenza vaccine and the timing of its distribution
cannot be guaranteed in any year.
Code 9, none of the above, if none of the listed reasons describe why the influenza
vaccine was not administered.
This code is also used if the answer is unknown.
So let's do a practice scenario for coding O0250.
Mrs. J received the influenza vaccine in the LTCH during this year's influenza vaccination
season on October 2 of 2017.
How would you code O0250 and what is your rationale?
This is not a polling question.
So here we can go through O0250A.
So A would be coded as 1, Yes, because we know that she did receive the vaccination.
So O0250A would be coded as 1, Yes,
And then we would skip O0250C because there's no reason that she did not receive the vaccination.
She did receive the vaccination.
Let's try another one.
O0250 Coding Scenario 2 has Mrs. T receiving the influenza vaccination at her
doctor's office during the year's influenza vaccination season.
Her doctor provided documentation of Mrs. T's receipt of the vaccine to the LTCH to
place in Mrs. T's medical record.
He also provided documentation that Mrs. T was explained the benefits and risks of the
vaccine prior to administration.
How would you code O0250?
And what is your rationale?
If you can think through A, B and C. So in this scenario O0250A would be coded 0, No.
She did not receive the vaccination in the LTCH.
We would then code O0250B by skipping that section.
So it's not coded.
And O0250C would be coded as 2, received outside of this facility.
She did receive it at her doctor's office.
And it was during this year's influenza vaccination season.
We have another coding scenario for O0250.
Mr. N was offered the influenza vaccine during his LTCH hospitalization beginning in February
2017.
Mr. N refused the influenza vaccine, asserting it always gave him the flu when he received
it in the past.
There's something we've never heard before right.
(Laughter) How would you code O0250, and what is your rationale?
So in this coding scenario we would code O0250A as 0, No.
It was not received in the facility.
We would skip O0250B.
And then we would move on to O0250C.
And we would code it as 4, offered and declined.
We did make the offer.
He refused it.
We should have good documentation of those refusals as well.
So in summary, Section O is a very important section for our patients who are at serious
risk.
Patients that are infected with influenza are at a higher risk for complications and
it's more likely that they require a higher level of care and hospitalization.
CDC does recommend an annual influenza vaccination, especially for at-risk populations.
And that overall is a summary of all of the sections that we've reviewed today.
We went through Section C, H, J for Falls and O, Influenza Vaccination.
None of those have changed.
We did add one clarification to Section B to include the non-verbal communication.
So we want to make sure that we communicate what we have learned today, or realized today,
through Action Planning back at our facilities.
So take the time to review the intent, rationale, and the steps for assessment for all of the
sections with your teams.
You'll likely get a better outcome and better documentation if people understand these aspects.
Review the language clarification that was made in Section B and its implication, making
sure that everyone understands we can now account for non-verbal communication.
Review the key dates related to the influenza vaccination season, being that we're right
in the middle of it at this point.
It's very important that everyone is aware and offering vaccination to our patients.
And practice coding a variety of scenarios with the staff.
There are scenarios that are located in the QRP Manual if you're looking for some to go
through with your staff and help them to practice coding scenarios as well.
I have about a minute and a half.
We covered a lot of content.
I don't know if anyone has any questions at this point or if you're all ready for lunch.
It's okay you can ask them.
»» I have a question.
»» Could you please come to the microphone if you wouldn't mind.
»» Sheila Brady from Baptist Health Extended Care.
In item C1610B when talking about the abnormal behavior fluctuating during the day, is that
day considered a 24-hour period or just during daylight time?
»» Would anyone like to clarify that?
The question was, when we're referencing "day" for the fluctuating behavior, are we referencing
the daytime hours or the 24-hour day as a whole?
»» We'll pause for a moment.
Good question.
»» 24 hours.
»» That's confirmed it's a 24-hour period.
Great question.
Thank you for clarifying.
Any others?
Thank you for your time.
-------------------------------------------
월 200만원 받던 31세 직장인 J씨 100만원으로 "이것" 시작 3년만에 8억 보유 자산가 되어 - Duration: 10:22.
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הליידי משלוט, תרגם וקורא יעקב שקד The Lady Of Shalott, in Hebrew - Duration: 14:16.
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我为喜剧狂收视率不敌欢乐喜剧人，苗阜何云伟联手惨败给郭德纲 - Duration: 4:53.
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潘玮柏送吴昕的生日祝福藏暗语，一爱就永远相爱 - Duration: 4:00.
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Projet : Interface Biométrique - Description du projet | Registre 02 - Journal de bord - Duration: 8:25.
Good morning, my name is Nicolas Sicard
I had the chance to participate in any kind of crazy projects!
I met tons of fascinating people, but above all, to experiment with
all kinds of technologies.
My current project was presented to me by Émile Beauchemin. My goal is to
create a system allowing a performer to control his environment through
his vital signs. To document my progress and share
my knowledge, I chose to produce this logbook and broadcast it on youtube,
to enable him to be accessible for all.
In this register, I will describe you of the project and explain briefly how
I put in place a precise description and complete. I think it's a step
absolutely essential to properly plan the after
and stay focused on the main goal.
The choice of elements to be included in a description is usually subjective.
the elements are often chosen according to the importance they have in the eyes of
the person who makes the description. In many areas, a subjective description
causes a biased understanding of the receiver. To avoid confusion, use
a method or procedure to follow that applies to any subject is necessary.
My method is to define first the purpose of the project. The goal is
the goal, the destination, the final result, the finish line. Once the goal
determined, I define my point of departure. The starting point is the situation
current, available resources, knowledge acquired competence and momentum is
to say, the current direction, the speed of change, the existing progression. It is
important to consider the momentum for to know if, without taking action, we are getting closer
of the goal or away from it.
Knowing the goal and the starting point, I can define the different options
currently visible. The different options are all actions, steps
and tools that bring you closer of the objective, which allows to redirect
the momentum of departure and which allow to make predictions about the sequence of events
and actions that can lead to the goal.
It's a pretty easy technique to memorize which also applies to any kind situation
of everyday life. So basically:we determine the goal and the starting point and we
list all possible paths to reach our goal.
The goal of the project is to produce a play in which a party
or all audiovisual elements are controlled by the vital signs of the performers.
So the lens has several aspects, including audiovisual, theater, biometrics (which
is the measure of biological elements) and programming.
We have the goal, now for what is the starting point, we are well positioned.
For the audiovisual aspect, I have a training and experience in the field. I
know how to program the audiovisual aspect of a play and I already have it
fact.
A particular element that has a meaning important is that usually, especially
for lighting, everything is programmed in advance in the form of sequences or profiles. during
the show, an operator simply makes alternated between different pre-record profiles.
It is from this norm that I have the intention to develop the rest.
As for the theatrical aspect, Émile takes care of it and he will take care of integrating
the tools I'm going to create at his piece. He makes me a list of the tools he would like
have and I do my best to make them as he describes them to me. The danger here is
poor communication My knowledge and his are a lot different,
so that he can imagine tools which are impossible to achieve with the
current resources and that it does not necessarily knowledge of everything that is possible,
which can limit his imagination and reduce the potential of the project.
For us to understand each other well, I used the same technique that I use to do
a description. I asked him his purpose, their current situation, from where they had
started, to be able to determine the momentum only to the project and which way they chose
to take to reach their goal !. I have have seen with its elements and with the uncertainty
he had in relation to the progression done, that the weak link was the
link between the technical aspect and the vision theatrical. It was this link that slowed down
the most progress. So it's an element to add to the to-do list
to reach our ultimate goal.
Regarding this Biometric aspect of the project they had already test some
sensors, like a sensor of muscular tension, a heart rate sensor and gyroscopes
which allow to record for example, movements of the head or hands of the
performer. They also have access to sensors skin moisture, temperature,
pressure and in my opinion the most interesting, an electroencephalogram, to record
the cerebral signals. What places us in a very good position is that they
had already programmed the transfer of given by OSC, which is a type of signal
which goes through the wifi and is very widespread in audiovisual theater and programming.
Since a lot of the work fact is based on the transfer by OSC, It
in fact the way that I have the most interest to take.
Finally, in terms of programming, the language I know best is python
and that's the language I'm going to use because there are already libraries
to handle OSC signals, for signals DMX, which are used to control lighting,
for all kinds of treatment tools audio, there are also all kinds of tools
mathematical visualization libraries data and signal interpretation.
Since we will not consolidate my programming into one application, which we
will not market it and that worries security is really minimal, I have
advantage to use python which is simpler and quick to write that for example c # or
Java.
So here is. The project consists in developing a way to control a scenic environment
thanks to the vital signs of a performer. It's a project that includes first, the establishment
and maintaining good communication between me and Emile, the type evaluation
of data transmitted by the sensors, the test of the different python libraries and
how to make them work together, eventually programming of several lighting profiles
and audio modification and obviously the programming the various tools that will be
used together to properly interpret the biometric signals and well used these
to change lighting profile and his.
To explain all this in detail, it's far from being what I prefer.
already a big project without that .. I'm afraid to lack motivation or to miss
time to fully explain everything respecting the format that I chose .. but ...
I will speak more specifically of my progress, my trials, my successes
and my failures .. It's going to be a lot more interesting for me than to analyze techniques
that I have been using automatically for years ...
For the next register, I will talk to you briefly of how I separate a project
or a problem in several elements in you speaking a little bit what I did up
now and how I could have saved a week of work if I had used
my own techniques and tips. I go then probably put order in
my files and show you a little what I have done so far, in you
showing also how you can have access to my codes to do tests you
even.
Thanks a lot for your presence, let I know what you think about them in
comments and subscribe to see the after.
That's all for today! We'll see you again in the next register, pass a good
day, a good week and see you. Bye!
-------------------------------------------
与刘亦菲分手，网友却发现宋承宪一动向，与一90后女星关系亲密 - Duration: 4:49.
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杨采钰自称是哥伦比亚大学毕业的，靳梦佳冯提莫表示不服 - Duration: 4:23.
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Fifth Harmony's Dinah Jane Performs "You're Welcome" from Moana | Lip Sync Battle - Duration: 0:44.
♪ You're welcome ♪
♪ You're welcome ♪
♪ Well come to think of it ♪
♪ Kid honestly I could go on and on ♪
♪ I could explain every natural phenomenon ♪
♪ The tide the grass the ground ♪
♪ All that was Maui just messing around ♪
♪ I killed an eel ♪
♪ I buried its guts ♪
♪ Sprouted a tree ♪
♪ Now you got coconuts ♪
♪ What's the lesson ♪
♪ What is the takeaway ♪
♪ Don't mess with Maui ♪
♪ When he's on a breakaway ♪
- I was not expecting any of it.
(audience laughing)
First the pig came out, and I said, huh?
(audience laughing)
But you looked so good, girl.
Your musckles are all poppin'.
(energetic music)
- [Announcer] New Lip Sync Battle,
Thursday at 10 on Paramount Network.
-------------------------------------------
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Yanzhe Ma - Computer Science student from Northwestern Polytechnical University - Duration: 1:33.
Hello everyone my name is Yanzhe Ma and I'm from the Northwestern Polytechnical
University and come here to Binghamton University for the master's
degree and I'm from the computer science department As for Binghamton,
I think it is a pretty good university.
Firstly, the environment: the air is fresh and clear, which is quite different from
China. And secondly, the food is delicious, not only
has the steak pizza, but also has the Chinese food.
I love it! And I know it's a very important part,
for the education: the professors are very nice, they will
answer all the question you ask, and actually the homework is very heavy.
In fact, I only spent three months here, but the code I
wrote is quite different and difficult than the code I
wrote in China which I spent there three years.
-------------------------------------------
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Academy of Art University For more infomation >> Academy of Art University-------------------------------------------
정상훈 아내, 정상훈 칭타오 이유, 이태임 정상훈 키스신, 정상훈 김생민 미담, 정상훈 나이|K-News - Duration: 5:09.
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가수 지나 무혐의?, 지나 성매매, 지나 원정성매매 지나, 지나 근황, 지나 컴백?|K-News - Duration: 4:14.
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Marvel Black Panther Vibranium Suit Basic Hasbro Movie Action Figure Review - Duration: 10:21.
Marvel Black Panther Vibranium Suit Basic Hasbro Movie Action Figure Review - After
the events of Captain America: Civil War, King T�Challa returns home to Wakanda.
But when two enemies conspire to bring down the kingdom, T�Challa must team up, as the
Black Panther, with CIA agent Everett K. Ross and members of
the Dora Milaje�Wakanda's special forces�to prevent a world war The king of the fictional
African nation of Wakanda, who gains enhanced strength by ingesting the Heart-Shaped Herb
After the events of Captain America: Civil War, and the death of his father T'Chaka,
T'Challa is in mourning while ascending to the throne
Kids will love recreating exciting battles for the fate of Wakanda with these 6� figures.
Made with true to movie styling and 7 points of articulation for lots of cool battle poses.
Kids can collect all their favourite characters inspired by the Marvel Black Panther movie
such as Black Panther, Erik Killmonger and Shuri
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Marvel Black Panther Vibranium Suit Basic Hasbro Movie Action Figure Review
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జనాకర్షణ, వశీకరణ శక్తీ పొందాలంటే | How to Get Popular In Business | Popular In All Fields - Duration: 2:55.
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