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Subsequent observation care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: Problem focused interval history; Problem focused examination; Medical decision making that is straightforward or of
CPT4 code
Name of the Procedure:
Subsequent Observation Care, per day
- Common Name: Follow-up Observation
- Technical Terms: Observation Care, E&M (Evaluation and Management)
Summary
This is a daily follow-up evaluation for patients who have already been admitted for observation. The assessment includes monitoring the patient’s progress and making necessary adjustments to their treatment plan.
Purpose
- Medical Conditions Addressed: Acute medical issues that require close monitoring but not immediate hospitalization.
- Goals/Outcomes: To ensure the patient's condition is stable or improving, and to adjust treatment as needed to prevent deterioration or complications.
Indications
- Symptoms like chest pain, shortness of breath, or abdominal pain.
- Conditions requiring short-term observation, such as monitoring after a minor procedure or treatment for a transient illness.
Preparation
- Generally, no special preparation is required.
- Patients should inform healthcare providers of any new symptoms or changes in their condition.
- Routine diagnostic tests might be performed as needed.
Procedure Description
- History Evaluation: Review of the patient's progress since the last observation, focusing on new or ongoing symptoms.
- Physical Examination: A problem-focused examination targeting specific areas related to the patient’s current condition.
- Medical Decision Making: Analysis and straightforward decision-making regarding the patient's treatment plan, which may include ordering additional tests or adjusting medications.
- Tools/Equipment: Stethoscope, blood pressure cuff, and other routine examination tools.
- No Anesthesia or Sedation: This procedure does not require sedation.
Duration
- Typically takes 15 to 30 minutes.
Setting
- Performed in a hospital observation unit or inpatient setting.
Personnel
- Primary Care Physician or Hospitalist
- Nurses
Risks and Complications
- Common Risks: Minimal, as it is a non-invasive procedure.
- Rare Complications: Misinterpretation of symptoms or delayed diagnosis, which could affect patient outcomes.
Benefits
- Expected Benefits: Accurate monitoring of patient’s condition and timely adjustments to the treatment plan.
- Realization: Benefits are typically realized immediately, ensuring the patient’s condition does not worsen and improving overall outcomes.
Recovery
- Post-Procedure Care: Follow any new instructions provided by the healthcare team.
- Recovery Time: No recovery time needed since the procedure is a routine check.
- Follow-Up: Daily assessments until the patient is discharged from observation.
Alternatives
- Other Options: Direct discharge with outpatient follow-up if the condition is deemed stable enough.
- Pros and Cons: Outpatient follow-up might be less costly but carries a higher risk if the patient’s condition worsens without proper monitoring.
Patient Experience
- During the Procedure: Patients might feel slight discomfort during a physical examination but otherwise should experience minimal discomfort.
- After the Procedure: Patients should feel reassured and informed about their health status and next steps.
- Pain Management: Typically, no pain management is required, as the procedure is non-invasive.