For critical care you need BOTH a critically ill patient, AND the provision of critical care. And, yes, the description of the care provided and the condition of the patient have to be complete. This can, in fact, be accomplished in a couple of sentences.
If I'm reading your post correctly, your physician's note reads:
Recurrent VT -discussed with pt and family the need for cath to rule out active ischemia as a cause of v.t. Managed antiarrythmia (amiodarione) stared beta blocker, arranged cardiac cath and ep eval. Ischemic cardiomyopathy -assessed possible volume overload and began beta blocker.
(I'm assuming there is time recorded somewhere, or you wouldn't even be considering critical care.) I think your physician needs to improve his description of actions/treatment taken. I see mention of amiodarone, but can't tell whether THIS physician was providing this management effort or whether this is part of the patient's history.
One more sentence to the effect that this patient is critically ill and at risk for further CV compromise without continuous monitoring, additional drug therapy, and further workup to determine root cause of VT would be enough.
F Tessa Bartels, CPC, CEMC
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