Subsequent hospital 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 moder
CPT4 code
Name of the Procedure:
Subsequent Hospital Care, Per Day (Evaluation and Management)
Common Name(s): Follow-up hospital visit, Daily inpatient care
Technical/Medical Term: Subsequent hospital care, per day, for the evaluation and management of a patient
Summary
Subsequent hospital care is a medical evaluation and management service provided to hospitalized patients on a daily basis. This involves a follow-up visit by healthcare providers to assess and manage the patient's progress during their hospital stay.
Purpose
Medical Condition or Problem:
- Ongoing inpatient medical, surgical, or psychiatric conditions.
- Monitoring of acute or chronic medical issues during hospitalization.
Goals or Expected Outcomes:
- To ensure continuous monitoring and management of the patient's condition.
- To make necessary adjustments to treatment plans.
- To assess the patient's progress and plan for discharge.
Indications
Specific Symptoms or Conditions:
- Postoperative monitoring.
- Acute illness requiring inpatient care.
- Chronic condition exacerbation.
- Complex medical management.
Patient Criteria:
- Hospitalized patients needing daily monitoring.
- Patients requiring adjustments to their treatment plans based on their condition.
Preparation
Pre-procedure Instructions:
- No specific preparation from the patient is required.
Diagnostic Tests or Assessments:
- Review of patient's medical records and recent test results.
- Physical examination and patient history update.
Procedure Description
Detailed Step-by-Step Explanation:
- Review of Medical Record: The healthcare provider reviews the patient's chart, including recent diagnostic test results and previous notes.
- Expanded Problem-Focused Interval History: The provider gathers recent updates from the patient regarding their symptoms, response to treatment, and any changes since the last visit.
- Expanded Problem-Focused Examination: A focused physical examination targeting problem areas (e.g., heart, lungs, abdomen).
- Medical Decision Making of Moderate Complexity: Based on the history and examination, the provider makes clinical decisions regarding changes in treatment, further diagnostic testing, or any other necessary interventions.
- Documentation: All findings and decisions are documented in the patient's medical chart.
Tools/Equipment:
- Stethoscope, blood pressure cuff, thermometer, and other basic diagnostic tools.
Anesthesia/Sedation:
- Not applicable.
Duration
Typically takes 20-30 minutes per visit.
Setting
Performed in a hospital setting, either at the patient's bedside or in a consultation room.
Personnel
- Physician (Attending, Resident, or Hospitalist)
- Nurse (for assistance and follow-up care)
- Other specialists as needed based on the patient's condition.
Risks and Complications
Common Risks:
- Minimal, as this is primarily an evaluative procedure.
Possible Complications:
- Miscommunication or oversight of critical information (managed through thorough documentation and clear communication among the healthcare team).
Benefits
Expected Benefits:
- Continuous assessment and timely management of the patient's condition.
- Early identification and intervention for any developing issues.
- Potential reduction in hospital stay duration.
Realization of Benefits:
- Typically immediate, with daily adjustments to optimize patient care.
Recovery
Post-Procedure Care:
- No specific recovery required as this is an evaluative visit.
Expected Recovery Time:
- Not applicable.
Restrictions/Follow-up:
- Continued daily evaluations until the patient is stable and ready for discharge.
Alternatives
Other Treatment Options:
- Remote monitoring (where applicable and technologically feasible).
- Outpatient follow-ups for less critical cases.
Pros and Cons of Alternatives:
- Remote monitoring can reduce inpatient costs but may not be suitable for all patients.
- Outpatient follow-ups are less intensive and may not catch complications as quickly.
Patient Experience
What to Expect During and After the Procedure:
- During the visit, the patient can expect questions about their condition and a physical examination.
- The process is generally non-invasive and should cause no more than mild discomfort.
- After the visit, patients should feel reassured about their treatment plan and any updates to their care.
Pain Management and Comfort Measures:
- Typically not necessary, but providers should ensure patient comfort and address any concerns.