Name of the Procedure:

Initial Hospital Care, Per Day (Evaluation and Management)

• Common names: Inpatient Daily Care, Initial Inpatient Evaluation
• Technical term: Initial Hospital Care, CPT Code 99221

Summary

Initial hospital care involves a comprehensive assessment and management of a patient's health condition during their first day in the hospital. This includes taking a thorough medical history, performing a detailed physical examination, and making moderately complex medical decisions regarding diagnosis and treatment.

Purpose

• Medical Condition Addressed: Broadly applicable to any condition requiring hospitalization and thorough assessment.
• Goals: To diagnose the patient's condition accurately, develop a treatment plan, and initiate appropriate medical interventions.

Indications

• Symptoms such as severe pain, difficulty breathing, or other acute symptoms requiring hospitalization.
• Chronic conditions that have worsened and need careful monitoring and intervention.
• Post-surgical recovery needing close medical supervision.

Preparation

• Pre-procedure Instructions: Patients should bring a list of current medications, allergies, and medical history.
• Diagnostic Tests: May include blood tests, imaging studies (e.g., X-rays, MRI), and other relevant diagnostics.

Procedure Description

1. Comprehensive History: Physician takes a detailed medical history, including current symptoms, past medical history, family history, and social history.
2. Comprehensive Examination: A thorough physical examination is conducted to assess the patient's condition.
3. Medical Decision Making: Based on the history and examination, the physician makes a moderately complex medical decision regarding diagnosis and treatment.
4. Counseling/Coordination: May involve discussing the treatment plan with the patient and coordinating with other healthcare professionals.

Duration

Typically 1 hour, though this can vary based on the complexity of the case.

Setting

Performed in a hospital setting, usually in the patient's room or an examination area.

Personnel

• Attending Physician or Specialist
• Residents or Interns (in teaching hospitals)
• Nurses
• Possibly other healthcare professionals like social workers or dietitians

Risks and Complications

• Common Risks: Misdiagnosis or delayed diagnosis if symptoms are atypical.
• Rare Risks: Adverse reactions to initial treatments or interventions.

Benefits

• Accurate diagnosis and prompt treatment initiation.
• Coordination of care leading to better health outcomes.
• Immediate response to any acute changes in patient condition.

Recovery

• Post-Procedure Care: Continued monitoring and adjustment of the treatment plan as needed.
• Recovery Time: Varies widely based on the underlying condition; generally ongoing until the patient is stable or discharged.
• Restrictions: Specific to the patient's diagnosis and treatment plan.
• Follow-Up: Regular check-ins by the medical team, with adjustments made as necessary.

Alternatives

• Alternative Treatment Options: Outpatient care for less severe conditions, telemedicine consultations for initial evaluation.
• Pros and Cons: Outpatient care offers convenience but may lack the comprehensiveness of inpatient care.

Patient Experience

• During Procedure: Patients may feel anxious or uncomfortable during examination and history taking but should experience minimal physical discomfort.
• Post-Procedure: Patients might feel relief from receiving a clear diagnosis and treatment plan. Pain management and other comfort measures will be provided as needed.