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

1. History Evaluation: Review of the patient's progress since the last observation, focusing on new or ongoing symptoms.
2. Physical Examination: A problem-focused examination targeting specific areas related to the patient’s current condition.
3. 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.