Emergency Care And Monitoring Template
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1
2Emergency Care and Monitoring - 81 Billable for Active Hands on Life Saving Management ONLY:
Please note that fee item 81 is not payable for managing Pt’s family, discussions with other health care professionals, arranging
transfers etc. Payable ONLY for the period of active hands on life saving management.
Doctor Name ______________________________________
Pt Name __________________________________________
(Please attach ER sheet or Pt label)
Date of Service _____________________ Pls indicate if you were __ second Dr on code __ third Dr on code
1st ½ hr ________ to _______
2nd ½ hr ________ to _______
3rd ½ hr ________ to _______
_____ cardiac arrest
_____ cardiac arrest
_____ cardiac arrest
_____ respiratory arrest
_____ respiratory arrest
_____ respiratory arrest
Other ____________________
Other ____________________
Other ____________________
_____ ACLS protocols
_____ ACLS protocols
_____ ACLS protocols
_____ bagged
_____ bagged
_____ bagged
_____ cardioversion
_____ cardioversion
_____ cardioversion
_____ catheter insertion
_____ catheter insertion
_____ catheter insertion
_____ central line insertion
_____ central line insertion
_____ central line insertion
_____ CPR
_____ CPR
_____ CPR
_____ infusion
_____ infusion
_____ infusion
_____ intubated
_____ intubated
_____ intubated
_____ IV meds
_____ IV meds
_____ IV meds
_____ O2
_____ O2
_____ O2
_____ transfusion
_____ transfusion
_____ transfusion
_____ ventilated
_____ ventilated
_____ ventilated
Other: ____________________
Other: ____________________
Other: ____________________
__________________________
__________________________
__________________________
4th ½ hr ________ to _______
5th ½ hr ________ to _______
6th ½ hr ________ to _______
_____ cardiac arrest
_____ cardiac arrest
_____ cardiac arrest
_____ respiratory arrest
_____ respiratory arrest
_____ respiratory arrest
Other ____________________
Other ____________________
Other ____________________
_____ ACLS protocols
_____ ACLS protocols
_____ ACLS protocols
_____ bagged
_____ bagged
_____ bagged
_____ cardioversion
_____ cardioversion
_____ cardioversion
_____ catheter insertion
_____ catheter insertion
_____ catheter insertion
_____ central line insertion
_____ central line insertion
_____ central line insertion
_____ CPR
_____ CPR
_____ CPR
_____ infusion
_____ infusion
_____ infusion
_____ intubated
_____ intubated
_____ intubated
_____ IV meds
_____ IV meds
_____ IV meds
_____ O2
_____ O2
_____ O2
_____ transfusion
_____ transfusion
_____ transfusion
_____ ventilated
_____ ventilated
_____ ventilated
Other: ____________________
Other: ____________________
Other: ____________________
__________________________
__________________________
__________________________
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