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Documentation Tip: Ebola

Posted on Tue, Oct 21, 2014
Documentation Tip: Ebola

By Dr. Timothy Brundage

Good documentation is important for new physicians as well as veteran caregivers. While documenting can seem like a very straightforward skill, there are often “best practices” that can be utilized. As a hospitalist for EmCare at St. Petersburg General Hospital in St. Petersburg, FL I write a “weekly documentation tip” email to help physicians improve their clinical documentation. I also share these documentation strategies with the residents I teach.

Documentation Tip: Ebola


With the rising concern regarding Ebola Virus Disease (EVD) and its spread to the United States, this tip of the week is unfortunately hitting too close to home.

Did you know:
In ICD-9, Ebola first codes to “Fever”, then “Hemorrhagic”, then “Ebola”, for ICD-9 code O65.8. In the coming ICD-10 this will then be A98.4.
Symptoms may appear anywhere from 2-21 days after exposure, averaging 8-10 days. Ebola is transmitted through direct contact with bodily fluids. Individuals are not contagious with Ebola until he/she has symptoms of the disease.

Important Screening Questions for ALL patients:
1) Have you traveled to Guinea, Sierra Leone, Liberia, Democratic Republic of the Congo, and Lagos, Nigeria in the past 30 days?
2) Do you have ANY of the following symptoms: fever (subjective or  101.5), muscle pain, severe headache, abdominal pain, diarrhea, vomiting, unexplained bleeding or bruising?
3) Have you been in contact with a known Ebola patient in the past 21 days?

If NO to question #1 or #3 there is a low probability of EVD and the patient should be evaluated as they normally would.

If YES to any of the above questions, isolate the patient in a private room with single bathroom and implement standard, contact and droplet precautions. Immediately notify your hospital infection control personnel and local County Health Department. The key is early detection and containment of the virus.

Reference: www.cdc.gov

ABOUT THE AUTHOR

Timothy N. Brundage, M.D., CCDs is a Certified Clinical Documentation Specialist and Diplomate of the American Board of Internal Medicine. Be sure to visit BrundageMedicalGroup.com and facebook.com/BrundageMedicalGroup.

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