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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: An expanded problem focused interval history; An expanded problem focused examination; Medical decision making of mo
CPT4 code
Name of the Procedure:
Subsequent Observation Care, Per Day (Evaluation and Management of a Patient)
Summary
Subsequent Observation Care involves daily follow-up evaluations to monitor a patient's condition during their stay in an observation unit. The care typically requires a focused review of the patient's interval history, an expanded physical examination, and moderate complexity medical decision-making.
Purpose
To closely monitor the health and progress of patients in an observation unit. The goal is to ensure timely and appropriate medical management, adjust treatments as needed, and decide on whether to admit the patient for inpatient care or discharge them.
Indications
- Acute conditions requiring detailed observation (e.g., chest pain, asthma exacerbations).
- Post-surgical monitoring.
- Conditions needing further evaluation to determine the need for inpatient admission.
- Response to treatment being closely monitored over a short period.
Preparation
- Patients are typically already under observation; no special preparation is necessary.
- Ongoing assessments and tests are conducted based on the patient's condition.
Procedure Description
- Review of Interval History: The healthcare provider reviews recent changes in the patient's symptoms and overall condition.
- Expanded Physical Examination: Conduct a thorough physical examination focusing on changes since the last assessment.
- Medical Decision Making: Evaluate current diagnostic findings, patient's response to treatment, and possible adjustments in the management plan.
Tools and Equipment:
- Stethoscope, blood pressure monitor, thermometer, and other examination tools.
- Access to patient's medical records and diagnostic test results.
Anesthesia/Sedation:
- Not applicable as this is an evaluation and management procedure.
Duration
Approximately 20-30 minutes per session.
Setting
- Hospital observation unit.
Personnel
- Attending physician or qualified healthcare provider.
- Nurses and support staff for assistance and documentation.
Risks and Complications
- Minimal risks from the daily evaluation itself.
- Risks are generally associated with underlying medical conditions and treatments being administered.
Benefits
- Continuous monitoring to ensure appropriate and timely medical management.
- Potential for early detection of complications.
- Helps in deciding swift and accurate admission or discharge.
Recovery
- Patients continue to receive care as needed based on their specific conditions.
- Some patients may be discharged with follow-up instructions, others may be admitted for further inpatient care.
Alternatives
- Direct discharge with outpatient follow-up.
- Immediate inpatient admission without observation.
- Each alternative is considered based on the patient's condition and the need for continuous monitoring.
Patient Experience
- Patients should expect regular interaction with healthcare providers for assessments.
- Minimal discomfort, associated mainly with routine physical exams.
- Pain management is addressed as part of the ongoing care plan, with efforts to ensure patient comfort.