Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: A problem focused interval history; A problem focused examination; Medical decision making that is straightforward or o
CPT4 code
Name of the Procedure:
Subsequent Hospital Care, per day, for the Evaluation and Management of a Patient
Summary
This procedure involves daily care for hospitalized patients, focusing on problem-specific interval history, examination, and straightforward medical decision-making. It's a continuous process aimed at monitoring and managing patient progress.
Purpose
The purpose of this procedure is to manage and evaluate the condition of hospitalized patients. It ensures that any changes in the patient’s status are quickly addressed and that ongoing treatments are effective.
Indications
- Worsening of chronic conditions
- Acute medical issues requiring hospitalization
- Post-surgery monitoring and care
- Complications from existing treatments or conditions
Preparation
- No specific preparations are typically necessary for the patient daily.
- Pre-hospitalization assessments and tests would already have been performed.
Procedure Description
- Problem Focused Interval History: The healthcare provider asks the patient about new and existing symptoms and any changes since the last visit.
- Problem Focused Examination: A physical examination that looks at specific body systems related to the patient's current issues.
- Medical Decision Making: Evaluation of the patient's condition to make straightforward medical decisions regarding treatment plans or necessary adjustments.
Tools and technology used may include patient charts, electronic medical records, and diagnostic tools like stethoscopes. No anesthesia or sedation is required.
Duration
Each daily evaluation typically takes between 15 to 30 minutes.
Setting
This procedure is performed in a hospital setting.
Personnel
- Attending Physician
- Resident Doctors
- Nurses
- Specialists (if needed)
Risks and Complications
- Misinterpretation of patient symptoms could lead to incorrect management.
- Delay in identifying new or worsening problems.
- Hospital-acquired infections due to prolonged hospitalization.
Benefits
- Close monitoring allows for timely adjustments in treatment.
- Early detection and management of complications.
- Improved overall patient outcomes through continuous care and evaluation.
Recovery
- Post-procedure care involves continuous monitoring by hospital staff.
- Daily reassessment until recovery or discharge.
- Specific instructions will be provided based on the patient's condition.
Alternatives
- Outpatient follow-up care for less severe conditions.
- Telemedicine consultations for monitoring if patients are stable and require minimal intervention.
- Short-term observation units for conditions needing brief monitoring.
Patient Experience
During daily evaluations, patients will typically experience:
- Routine questioning about their health.
- Physical examinations which may cause minor discomfort.
- Interaction with various health professionals ensuring comprehensive care. Pain management and other comfort measures should be consistently addressed as part of ongoing care.