Critical Care Documentation
Critical care notes must be a minimum of 35 minutes; there is no max CC time.
If using a template, edit the note to accurately reflect the patient’s condition, interventions, and your medical decision making.
We added a critical care AI prompt to the scribe app.
Any patient placed in OBS more than 8 hours qualifies for critical care.
Section 1: Generic Statements
Section 2: Condition Specific
Allergic / Immune
Cardiopulmonary
Dehydration / Fatigue
Gastrointestinal
Medical Withdrawal Stabilization (MWS)
Neurologic
Other High-Risk Categories
Generic Critical Care Phrases
The patient presents with an illness or injury that acutely impaired one or more vital organ systems. There was a high probability of imminent or life threatening deterioration in the patient’s condition during their evaluation in the ED. This is the total time spent evaluating, coordinating, managing, and providing care to the critical patient, as well as time spent in documenting such activities. This time is exclusive of time required to perform procedures required during patient management.
Patient presents with a problem that potentially represents a highly morbid condition with a possible threat to life or bodily function.
There was a high probability of imminent or life-threatening deterioration in the patient’s condition.
Tests were independently reviewed and interpreted by me.
The patient presents with an illness or injury that acutely impaired one or more vital organ systems.
Considered hospitalization or emergent surgery/procedure.
Controlled parenteral medications or medications requiring intensive monitoring were administered.
Generic CC Time Statements
This is the total time spent evaluating, coordinating, managing, and providing care to the critical patient… exclusive of time required to perform procedures.
Critical care performed (35 minutes). Time is exclusive of separately billable procedures.
Time includes: direct patient care, patient reassessment, coordination of patient care, interpretation of data, review of records, family consultation, and documentation.
Procedures included in critical care time: peripheral IV placement and phlebotomy.
Multiple emergent interventions were required to prevent sudden life-threatening deterioration.
Complexity & High-Risk Phrases
Patient presents with a problem that potentially represents a highly morbid condition with a possible threat to life or bodily function.
Tests were independently reviewed and interpreted by me.
Considered hospitalization or emergent surgery/procedure.
Controlled parenteral medications or medications requiring intensive monitoring were administered.
Discussion of management with another professional.
High-Risk Differential Diagnosis
These are differential lines describing life- or organ-threatening conditions, combine these with the generic CC templates
DDxAbnmlLabs → DKA, significant blood loss anemia, significant metabolic disturbances.
DDxAMS → seizure, toxic ingestion, sepsis, severe sepsis, significant metabolic disturbances.
DDxCVA → CVA, acute neurological change, significant metabolic disturbances.
DDxSeizure → seizure, toxic ingestion, sepsis, severe sepsis, significant metabolic disturbances.
DDxSepsis → aignificant infection, significant metabolic disturbance, sepsis, severe sepsis.
DDxHTN → hypertensive crisis, hypertensive urgency/emergency
DDxSOB → congestive heart failure, cardiac ischemia, arrhythmia, pulmonary embolism, COPD exacerbation
Generic Observation Statement
The patient was placed into Observation status due to the need for ongoing evaluation, monitoring, and treatment to determine clinical stability and safe disposition. At the time of decision-making, the patient did not meet criteria for discharge due to ongoing symptoms, abnormal diagnostics, risk of deterioration, and the need for serial reassessments.
During Observation, the following care was required:
Serial reassessments and vital sign monitoring
Review and trending of laboratory findings
Repeat examination to ensure no evolving emergency condition
Ongoing treatment response evaluation
Adjustment of care plan based on clinical changes
Patient education and discharge safety planning
The patient will remain in Observation until:
Symptoms have improved
Vital signs and exam findings stabilize
Lab/imaging trends are reassuring
Treatment goals have been achieved
Safe discharge criteria are met
OR transfer/admission becomes necessary
Observation remains the safest and most appropriate level of care at this time due to the risk of clinical deterioration without continued monitoring and treatment.
Allergic Reaction/Anaphylaxis/Systemic Rash
Critical Care Time:
I provided ___ minutes of non-concurrent critical care time. This excludes separately billable procedures. Time included bedside management, reassessments, review of diagnostics, documentation, and communication with parents and staff.
Reason for Critical Care
Critical care services were required due to the high risk of sudden, clinically significant deterioration from acute allergic reaction with concern for anaphylaxis, including airway compromise, hypoxia, hypotension, bronchospasm, and cardiovascular collapse. Immediate intervention was necessary to prevent life-threatening respiratory failure or shock.
Critical Care Interventions Performed
I personally provided the following critical care services:
Airway assessment and protection
Administration of IM epinephrine
Administration of IV antihistamines
Administration of IV steroids
Nebulized bronchodilators for wheezing/bronchospasm
IV fluids for hypotension or poor perfusion
Supplemental oxygen
Continuous cardiac and pulse-oximetry monitoring
Frequent reassessment of airway patency and respiratory status
Review and interpretation of labs, imaging, and EKG
Screening for biphasic reaction
Consideration of alternative diagnoses (angioedema, sepsis, asthma, cardiac causes)
Coordination with nursing staff regarding epinephrine timing, monitoring, and reassessment
Preparation for advanced airway management if deterioration occurred
Communication with patient/family regarding severity of reaction and emergency management
Review of prior records for allergy history
These interventions were necessary to prevent respiratory compromise, circulatory collapse, or death.
Observation Note:
The patient was placed into Observation status due to ongoing risk associated with an acute allergic reaction with potential for anaphylaxis, requiring continued monitoring, treatment, and reassessment to ensure clinical stability and safe disposition. At the time Observation was initiated, the patient was not yet suitable for discharge due to continued symptoms, risk of rebound reaction, and the need for serial evaluations.
Cardiopulmonary
Chest Pain
Critical Care Time:
I provided ___ minutes of non-concurrent critical care time. This excludes separately billable procedures. Time included bedside management, reassessments, review of diagnostics, documentation, and communication with parents and staff.
Reason for Critical Care
I provided critical care due to the high probability of sudden, clinically significant deterioration related to acute chest pain of unclear etiology, with concern for potentially life-threatening conditions including acute coronary syndrome (ACS), myocardial infarction, aortic dissection, pulmonary embolism, malignant arrhythmia, and hemodynamic instability. Immediate evaluation and treatment were required to prevent further deterioration.
Critical Care Interventions Performed
Critical care services personally performed include:
Immediate bedside evaluation and continuous reassessment
Review and interpretation of EKG, labs, and imaging
Establishment of IV access
Administration of ASA, nitroglycerin, IV fluids, or other medications as indicated
Continuous cardiac monitoring and pulse oximetry
Evaluation and exclusion of life-threatening causes of chest pain (ACS, PE, aortic dissection, pneumothorax, arrhythmia)
Ordering emergent diagnostic tests
Communication with nursing regarding hemodynamic monitoring
Discussion with patient regarding risks and treatment
Review of prior medical records (if available)
Coordination of care with appropriate receiving facility (if transferring)
These interventions were necessary to prevent deterioration, including potential arrhythmia, infarction, or hemodynamic compromise.
Observation Note
The patient was placed into Observation status due to ongoing evaluation needs for chest pain with potential cardiac, respiratory, vascular, or systemic causes. At the time Observation was initiated, the patient did not yet meet criteria for discharge due to persistent symptoms, abnormal or pending diagnostic results, risk factors, and the need for continued monitoring and serial reassessments.
During Observation, the patient requires:
Serial cardiac monitoring and vital signs
Repeat EKGs for ischemic changes
Trending of troponins or other cardiac biomarkers
Reassessment of chest pain pattern and severity
Monitoring for arrhythmias, hypoxia, or perfusion abnormalities
Ongoing treatment response evaluation
Consideration of PE evaluation, imaging, or risk stratification
Patient education and discharge risk counseling
Observation remains the safest and most appropriate level of care at this time due to the ongoing risk of cardiac ischemia, arrhythmia, or other emergent causes of chest pain without continued monitoring and diagnostic evaluation.
Cough/Bronchitis
Critical Care Time:
I provided ___ minutes of non-concurrent critical care time. This excludes separately billable procedures. Time included bedside management, reassessments, review of diagnostics, documentation, and communication with parents and staff.
Critical care interventions performed
Continuous cardiac, respiratory, and oxygen saturation monitoring
Serial respiratory assessments
Establishment of IV access
Administration of:
Nebulized bronchodilators
Steroids (oral/IV)
Oxygen therapy
IV fluids if dehydrated or septic concern
Interpretation of diagnostics:
CBC, CMP, lactate
Viral testing (COVID / Flu / RSV)
Blood cultures if sepsis suspected
EKG
Interpretation of imaging:
Chest X-ray
CTA chest if PE suspected
Evaluation for:
Hypoxia progression
Respiratory fatigue
Sepsis indicators
Hemodynamic instability
Consideration of antibiotics based on clinical suspicion
Counseling patient/family regarding diagnosis, risks, and treatment course
Coordination with respiratory therapy and nursing for escalation precautions
Consultation with hospitalist/pulmonology
Observation Note
The patient was placed into Observation status due to ongoing risk and clinical uncertainty related to cough and suspected bronchiolitis/respiratory illness, requiring continued monitoring, treatment, and reassessment prior to determining safe discharge. At the time Observation was initiated, the patient did not meet criteria for discharge due to persistent symptoms and the potential for respiratory deterioration.
During Observation, the patient requires:
Serial respiratory exams and reassessments
Continuous or intermittent pulse oximetry
Monitoring of feeding tolerance / hydration status (pediatric)
Repeat vitals to assess for deterioration
Monitoring response to bronchodilators or medications
Ongoing airway clearance techniques if indicated
Evaluation for progression to hypoxia or fatigue
Education on home care, return precautions, and infection guidance
Observation remains the safest and most appropriate level of care due to the risk of respiratory worsening, hypoxia, and clinical decline without continued monitoring and treatment.
Croup
Critical Care Time:
I provided ___ minutes of non-concurrent critical care time. This excludes separately billable procedures. Time included bedside management, reassessments, review of diagnostics, documentation, and communication with parents and staff.
Reason for Critical Care
The patient presented with acute respiratory distress secondary to croup, with symptoms including stridor, increased work of breathing, retractions, and possible hypoxia. Due to the potential for rapid airway compromise, the patient required high-level medical decision making, continuous monitoring, and aggressive respiratory support. The condition posed an imminent risk of respiratory failure without timely intervention; therefore, critical care time was medically necessary.
Critical Care Interventions Performed
Critical care time was spent evaluating and managing high-risk respiratory distress:
Continuous cardiorespiratory and oxygen saturation monitoring
Serial respiratory assessments evaluating stridor, retractions, and airway stability
Administration of nebulized racemic epinephrine
Administration of dexamethasone (oral/IM/IV per patient tolerance)
Oxygen therapy as needed
Evaluation and management for alternative or worsening etiologies (epiglottitis, foreign body, bacterial tracheitis, anaphylaxis)
Interpretation of diagnostic testing (if obtained): spotfire respiratory viral panel, neck/chest X-ray
Repeated reassessments after racemic epinephrine to monitor for rebound stridor
Clear communication with nursing staff regarding airway precautions
Extensive counseling with parents/guardians regarding severity, treatment plan, expected course, and warning signs requiring escalation
Preparation for advanced airway management if deterioration occurred
Observation Note
The patient was placed into Observation status due to ongoing risk and clinical uncertainty related to croup with potential airway compromise, requiring continued monitoring, treatment response evaluation, and serial reassessments prior to determining safe discharge. At the time Observation was initiated, the patient did not yet meet criteria for discharge due to continued symptoms and the possibility of respiratory deterioration.
During Observation, the patient requires:
Serial reassessment of stridor, air movement, and work of breathing
Monitoring for recurrence after epinephrine effect wears off
Continuous or intermittent pulse oximetry
Repeat vital signs
Hydration and feeding tolerance monitoring
Ongoing treatment response evaluation
Parent/caregiver education and return precautions
Observation remains the safest and most appropriate level of care at this time due to the risk of airway worsening and rebound respiratory distress without continued monitoring and treatment.
Hypoxia/Wheezing/SOB
Critical Care Time:
I provided ___ minutes of non-concurrent critical care time. This excludes separately billable procedures. Time included bedside management, reassessments, review of diagnostics, documentation, and communication with parents and staff.
Reason for Critical Care
Critical care was required due to the high risk of sudden deterioration from acute shortness of breath, with concern for respiratory failure, pneumonia, sepsis, asthma/COPD exacerbation, pulmonary embolism, heart failure, pneumothorax, and hypoxia. Immediate intervention was necessary to prevent life-threatening respiratory or cardiovascular compromise.
Critical Care Interventions Performed
I personally performed the following critical care activities:
Immediate assessment and stabilization
Continuous cardiac and pulse-oximetry monitoring
Supplemental oxygen (nasal cannula, non-rebreather, or as required)
Nebulized bronchodilators (DuoNeb/albuterol)
IV steroids (if indicated for reactive airway)
IV fluids (if hypotensive or dehydrated)
Review and interpretation of labs, imaging, and EKG
Screening for pneumonia, PE, sepsis, CHF, COPD/asthma exacerbation
Repeated bedside reassessments for respiratory status
Coordination with nursing staff for medication, oxygen adjustments, and monitoring
Discussion with radiology/receiving facility (if transferring)
Review of prior medical records
Preparation for possible airway intervention if deterioration occurred
These interventions were necessary to prevent respiratory failure, hypoxia, or cardiovascular collapse.
Observation Note
The patient was placed into Observation status due to ongoing respiratory symptoms including hypoxia, wheezing, and/or shortness of breath, requiring continued monitoring, serial assessments, and treatment response evaluation before a safe discharge determination could be made. At the time Observation was initiated, the patient did not yet meet criteria for discharge due to the risk of respiratory deterioration.
During Observation, the patient requires:
Serial respiratory assessments
Continuous or intermittent pulse oximetry
Monitoring of treatment response to bronchodilators/steroids
Vitals trending for respiratory or hemodynamic instability
Hydration and oral intake evaluation if ill or pediatric
Evaluation for pneumonia progression or need for escalation
Ambulation or sleep oxygenation checks
Education on inhaler/nebulizer use, triggers, and return precautions
Observation remains the safest and most appropriate level of care due to the risk of respiratory worsening, hypoxia, and potential decompensation without continued monitoring and treatment.
STEMI
Critical Care Time:
I provided ___ minutes of non-concurrent critical care time. This excludes separately billable procedures. Time included bedside management, reassessments, review of diagnostics, documentation, and communication with parents and staff.
Reason for Critical Care
The patient presented with acute chest pain and EKG findings consistent with STEMI, placing them at immediate risk for arrhythmia, cardiogenic shock, cardiac arrest, severe ischemia, and death. Emergent intervention and continuous monitoring were required. Critical care time was medically necessary due to the imminent risk of life-threatening deterioration.
Critical care management included:
Continuous cardiac and oxygen saturation monitoring
Serial vital signs and perfusion assessments
Immediate EKG interpretation demonstrating STEMI
Second confirmatory EKG when indicated
Establishment of IV access (multiple lines if needed)
Administration of:
Aspirin
Nitroglycerin if not hypotensive and no RV infarct
Antiemetics
Oxygen if hypoxic
Pain control
Evaluation for:
hypotension
bradycardia
ventricular arrhythmias
pulmonary edema
Interpretation of diagnostic studies:
CBC, CMP
Troponin
Coagulation panel
Magnesium/Phosphorus
Chest X-ray interpretation if obtained
EKG rhythm surveillance for deterioration
Identification of contraindications to thrombolytics
Transfer coordination with PCI-capable facility
Activation of STEMI protocol
Communication with EMS regarding transport urgency
Counseling patient/family regarding diagnosis, urgency, and transfer requirements
Ongoing reassessments for instability or arrest
Dehydration / Fatigue
Dehydration/Electrolyte Imbalance
Critical Care Time:
I provided ___ minutes of non-concurrent critical care time. This excludes separately billable procedures. Time included bedside management, reassessments, review of diagnostics, documentation, and communication with parents and staff.
Reason for Critical Care
I provided critical care due to the high probability of sudden, clinically significant deterioration resulting from severe dehydration, with concern for hypovolemia, electrolyte imbalance, acute kidney injury, hypotension, tachycardia, metabolic acidosis, and shock. Immediate intervention was required to prevent progression to cardiovascular collapse or organ dysfunction.
Critical care management included:
I personally provided the following critical care services:
Initiation and titration of intravenous fluid resuscitation (normal saline/LR)
Electrolyte replacement (as needed)
Ordering and interpretation of labs and EKG
Continuous cardiac and pulse oximetry monitoring
IV antiemetics for nausea/vomiting
Serial reassessments for hemodynamic stability
Evaluation and management of potential acute kidney injury
Exclusion of sepsis, DKA, and other high-risk causes of dehydration
Review of prior medical records (if available)
Coordination with nursing staff regarding fluid administration and monitoring
Assessment for need of transfer to higher level of care
These interventions were required to prevent progression to shock, dysrhythmia, or end-organ injury.
Observation Note
The patient was placed into Observation status due to ongoing clinical concern for dehydration and/or electrolyte imbalance, requiring continued IV therapy, monitoring, diagnostic trending, and serial reassessments before safe discharge could be determined. At the time Observation was initiated, the patient did not yet meet criteria for discharge due to persistent symptoms and risk of clinical deterioration.
During Observation, the patient requires:
Serial vital signs and perfusion monitoring
Repeat electrolyte panels and renal function trending
Continued IV hydration and medication administration
Monitoring of urine output and hydration tolerance
Orthostatic reassessment if indicated
Cardiac monitoring if potassium or magnesium abnormal
Continuous assessment for worsening dehydration or metabolic imbalance
Patient education regarding hydration and follow-up needs
Observation remains the safest and most appropriate level of care due to the risk of worsening dehydration, electrolyte instability, arrhythmia, renal compromise, and hemodynamic deterioration without continued monitoring and treatment.
Fatigue/Weakness
Critical Care Time:
I provided ___ minutes of non-concurrent critical care time. This excludes separately billable procedures. Time included bedside management, reassessments, review of diagnostics, documentation, and communication with parents and staff.
Reason for Critical Care
The patient presented with severe fatigue and generalized weakness, raising concern for potentially life-threatening underlying conditions such as sepsis, electrolyte derangements, metabolic crisis, acute anemia, dysrhythmia, stroke/TIA, intracranial hemorrhage, myasthenic crisis, adrenal crisis, or other causes of rapid decompensation. Given the high-risk differential and potential for sudden deterioration, the patient required critical care-level evaluation and management, including continuous monitoring, aggressive diagnostics, and frequent reassessments.
Critical Care Interventions Performed
I personally provided the following critical care services:
Continuous cardiac, respiratory, and hemodynamic monitoring
Serial neurologic checks and orthostatic vital assessments
IV access establishment and administration of IV fluids
Interpretation of laboratory studies, including: CBC, CMP, Mg/Phos, TSH, troponin, lactate, UA, pregnancy test (if applicable), COVID/flu, CK, and others as appropriate.
Interpretation of EKG for rhythm abnormalities or ischemia
Interpretation of chest X-ray, CT head, or other imaging as indicated
Evaluation for acute infectious sources
Assessment for dehydration, anemia, or metabolic disturbances
Management of electrolyte imbalances (K, Mg, Na abnormalities, glucose derangements)
Consultation with specialists if warranted (neurology, cardiology, hospitalist)
Ongoing reassessment to monitor for progression toward respiratory failure, cardiac instability, or neurologic compromise
Clear communication with nursing staff regarding monitoring parameters
Counseling the patient/family regarding findings, expected course, and potential need for admission or transfer
Observation Note
The patient was placed into Observation status due to ongoing clinical concern related to fatigue and generalized weakness, requiring continued monitoring, diagnostic evaluation, treatment response assessment, and serial examinations to determine safe disposition. At the time Observation was initiated, the patient did not yet meet criteria for discharge due to unresolved symptoms and risk of deterioration.
During Observation, the patient requires:
Serial vital signs and orthostatic reassessments
Repeat labs to evaluate trending and correction
Monitoring for neurologic changes or focal deficits
Cardiac rhythm evaluation
Fall-risk precautions and mobility reassessment
Hydration and oral intake tolerance checks
Ongoing evaluation for infectious or metabolic causes
Education on follow-up and safety precautions
Observation remains the safest and most appropriate level of care due to the risk of worsening weakness, fall risk, metabolic instability, cardiac or neurologic decline, and need for ongoing monitoring and diagnostic clarification.
Gastrointestinal
Abdominal Pain
Critical Care Time:
I provided ___ minutes of non-concurrent critical care time. This excludes separately billable procedures. Time included bedside management, reassessments, review of diagnostics, documentation, and communication with parents and staff.
Reason for Critical Care
I provided critical care due to the high probability of sudden, clinically significant deterioration related to acute abdominal pain of unclear etiology, with concern for potentially life-threatening conditions such as bowel perforation, sepsis, appendicitis, aortic aneurysm/dissection, mesenteric ischemia, ruptured ectopic pregnancy, obstruction, severe dehydration, or hemodynamic instability. Immediate evaluation and treatment were necessary to prevent further decompensation.
Critical Care Interventions Performed
I personally delivered the following critical care services:
Aggressive IV fluid resuscitation
IV analgesia and antiemetics
Ordering and interpretation of CT imaging, ultrasound, and laboratory results
Serial abdominal exams
Discussion with patient regarding high-risk differential and potential for surgery
Coordination with radiology and nursing staff
Evaluation for septic shock, hypovolemia, GI bleeding, or obstruction
Management of tachycardia and hypotension
Review of prior medical records
Initiation of antibiotics when indicated
Continuous monitoring and re-evaluation to prevent worsening instability
These interventions were necessary due to concern for potential deterioration including perforation, sepsis, hemorrhage, or ischemia.
Observation Note
The patient was placed into Observation status due to ongoing evaluation needs related to abdominal pain with potential for evolving intra-abdominal pathology, requiring continued monitoring, diagnostic trending, treatment response assessment, and serial examinations before a safe discharge determination could be made. At the time Observation was initiated, the patient did not yet meet criteria for discharge due to persistent symptoms and risk of clinical deterioration.
During Observation, the patient requires:
Serial vital signs and abdominal reassessments
Monitoring for peritoneal signs or worsening localization
Repeat labs or trending of abnormalities
Hydration and oral intake tolerance evaluation
Monitoring response to analgesics and antiemetics
Evaluation for surgical consultation if needed
Ongoing diagnostic clarification and disposition planning
Patient education and return precaution reinforcement
Observation remains the safest and most appropriate level of care due to the risk of evolving intra-abdominal pathology, dehydration, worsening pain, and the need for continued monitoring, diagnostic trending, and serial physical examinations.
Diarrhea
Critical Care Time:
I provided ___ minutes of non-concurrent critical care time. This excludes separately billable procedures. Time included bedside management, reassessments, review of diagnostics, documentation, and communication with parents and staff.
Reason for Critical Care
The patient presented with acute diarrhea with signs of potential volume depletion, electrolyte imbalance, sepsis, or gastrointestinal bleeding. Due to the risk of hemodynamic instability, severe dehydration, metabolic derangements, and progression to shock, the patient required critical care-level evaluation and management. This condition carried a risk of rapid deterioration requiring aggressive interventions; therefore, critical care time was medically necessary.
Critical Care Interventions Performed
I personally provided the following critical care interventions:
Continuous cardiac and respiratory monitoring
Establishment of IV access and Administration of IV fluids
Serial vital signs and orthostatic evaluations
Interpretation of diagnostic studies:
CBC, CMP, magnesium, phosphorus
Pregnancy test (if applicable)
Lactic acid
UA
Interpretation of EKG—for arrhythmias related to electrolyte abnormalities
Interpretation of abdominal imaging (CT abdomen/pelvis)
Electrolyte replacement (potassium, magnesium, sodium abnormalities)
Assessment for shock, sepsis, GI bleeding, or acute abdomen
Evaluation for red-flag findings such as:
Persistent tachycardia
Hypotension
Bloody diarrhea
Severe abdominal pain
Mental status changes
Communication with nursing staff for close monitoring
Consultation with gastroenterology or hospitalist if needed
Counseling the patient/family regarding findings, treatment plan, expected course, and possible admission or transfer
Observation Note
The patient was placed into Observation status due to ongoing clinical concern related to acute diarrhea, requiring continued monitoring, diagnostic evaluation, hydration assessment, and treatment response prior to determining safe discharge. At the time Observation was initiated, the patient did not yet meet criteria for discharge due to persistent symptoms and risk of deterioration.
During Observation, the patient requires:
Serial vital sign and perfusion monitoring
Trending of electrolytes and renal function
Hydration tolerance reassessment
Monitoring urine output
Evaluation for bloody stools or clinical escalation
Response assessment to IV fluids and medications
Fall-risk and weakness monitoring
Patient education regarding safe discharge and return precautions
Observation remains the safest and most appropriate level of care due to the risk of worsening dehydration, electrolyte imbalance, acute kidney injury, and clinical decline without continued monitoring and treatment.
GI Bleed
Critical Care Time:
I provided ___ minutes of non-concurrent critical care time. This excludes separately billable procedures. Time included bedside management, reassessments, review of diagnostics, documentation, and communication with parents and staff.
Reason for Critical Care
The patient presented with signs and symptoms concerning for an acute GI bleed, including hematemesis, melena, hematochezia, syncope, tachycardia, hypotension, pallor, dizziness, and/or abdominal pain. GI bleeding poses an imminent risk of shock, hemodynamic collapse, anemia requiring transfusion, and death, and necessitated high-level, time-sensitive medical decision making. Critical care time was required due to high risk of acute deterioration.
Critical Care Interventions Performed
I personally provided the following critical care interventions:
Continuous cardiac, respiratory, and pulse oximetry monitoring
Establishment of IV access and Aggressive IV fluid resuscitation with crystalloid boluses
Serial blood pressure and hemodynamic monitoring
Frequent reassessments for perfusion status and mental status
Interpretation of diagnostic studies including:
CBC, CMP, magnesium, phosphorus
PT/INR, PTT
Type & screen / type & cross
Lactate
Stool occult blood if indicated
Interpretation of EKG for arrhythmias or ischemia
Interpretation of imaging (CT abdomen/pelvis or CTA if obtained)
Assessment for need for blood transfusion
Evaluation of anticoagulant use and reversal requirements
Administration of medications as indicated:
Proton pump inhibitor (IV pantoprazole)
Antiemetics
Octreotide if upper GI or variceal bleed suspected
Antibiotics if variceal bleed suspected
Monitoring for signs of worsening shock or hemodynamic instability
Consultation with gastroenterology or hospitalist regarding possible transfer or admission
Extensive counseling with patient/family regarding severity, treatment plan, and potential need for higher level of care
Observation Note
The patient was placed into Observation status due to ongoing clinical concern for a gastrointestinal bleed, requiring continued monitoring, diagnostic trending, hemodynamic assessment, and treatment response evaluation prior to determining safe discharge. At the time Observation was initiated, the patient did not yet meet criteria for discharge due to persistent symptoms and risk of deterioration.
During Observation, the patient requires:
Serial vital sign and perfusion monitoring
Trending of electrolytes and renal function
Hydration tolerance reassessment
Monitoring urine output
Evaluation for bloody stools or clinical escalation
Response assessment to IV fluids and medications
Fall-risk and weakness monitoring
Patient education regarding safe discharge and return precautions
Observation remains the safest and most appropriate level of care due to the risk of continued bleeding, anemia progression, hemodynamic instability, and potential for rapid deterioration without continued monitoring and treatment.
Nausea and Vomiting
Critical Care Time:
I provided ___ minutes of non-concurrent critical care time. This excludes separately billable procedures. Time included bedside management, reassessments, review of diagnostics, documentation, and communication with parents and staff.
Reason for Critical Care
Critical care services were required due to the high risk of sudden, clinically significant deterioration related to severe nausea and vomiting, with concern for dehydration with hypovolemia, electrolyte imbalance, acute kidney injury, sepsis, GI obstruction, appendicitis, pancreatitis, DKA, toxic ingestion, or intracranial pathology. Immediate evaluation and treatment were required to prevent progression to shock, organ failure, or metabolic instability.
Critical Care Interventions Performed
I personally provided the following critical care services:
IV fluid resuscitation (initial bolus and reassessment)
IV antiemetics
Electrolyte replacement
Continuous cardiac and pulse-oximetry monitoring
IV medications for abdominal pain if needed
Review and interpretation of labs, UA, EKG, and imaging
Serial abdominal exams
Assessment for bowel obstruction, appendicitis, pancreatitis, or GI bleeding
Evaluation for metabolic derangements (DKA, acidosis)
Coordination with nursing staff regarding fluids and monitoring
Review of prior medical records
Preparation for possible transfer if worsening or abnormal findings
These interventions were necessary to prevent further dehydration, hemodynamic instability, or metabolic dysfunction.
Observation Note
The patient was placed into Observation status due to ongoing clinical concern related to nausea and vomiting, requiring continued monitoring, hydration assessment, diagnostic clarification, and treatment response evaluation prior to determining safe discharge. At the time Observation was initiated, the patient did not yet meet criteria for discharge due to persistent symptoms and risk of deterioration.
During Observation, the patient requires:
Serial vital signs and perfusion monitoring
Hydration tolerance reassessment
Repeat electrolytes and renal function trending
Monitoring for hematemesis or worsening abdominal pain
IV hydration and medication response evaluation
Ambulation and orthostatic reassessment
Determination of need for imaging or specialty consults
Patient education regarding diet advancement and return precautions
Observation remains the safest and most appropriate level of care due to the risk of worsening dehydration, electrolyte imbalance, acute kidney injury, and clinical decline without continued monitoring and treatment.
GU
Back/Flank Pain/Suspected Renal Stone
Critical Care Time:
I provided ___ minutes of non-concurrent critical care time. This excludes separately billable procedures. Time included bedside management, reassessments, review of diagnostics, documentation, and communication with parents and staff.
Reason for Critical Care
Critical care services were required due to the high risk of sudden, clinically significant deterioration related to acute back or flank pain, with concern for potentially life-threatening etiologies including abdominal aortic aneurysm (AAA), aortic dissection, renal colic with obstruction/infection, pyelonephritis with sepsis, spinal epidural abscess, spinal cord compression, or cauda equina syndrome. Immediate evaluation and management were necessary to prevent possible neurologic or hemodynamic collapse.
Critical Care Interventions Performed
I personally provided the following critical care interventions:
IV fluid resuscitation
IV analgesia
IV antiemetics
Antibiotics (if suspected pyelonephritis or sepsis)
Continuous cardiac and pulse oximetry monitoring
Assessment for aortic pathology, spinal cord compression, or urosepsis
Review and interpretation of labs, UA, imaging (CT/Ultrasound)
Repeated abdominal and neurological exams
Coordination with nursing regarding hydration, medication titration, and monitoring
Preparation for emergent transfer if imaging concerning
Review of prior medical and radiology records
Discussion of findings and risks with patient/family
These interventions were necessary to prevent rapid deterioration related to AAA rupture, obstructive pyelonephritis, spinal cord compromise, or sepsis.
Observation Note
The patient was placed into Observation status due to ongoing evaluation needs related to back or flank pain with suspected renal stone, requiring continued monitoring, diagnostic clarification, pain control assessment, and serial examinations prior to determining safe discharge. At the time Observation was initiated, the patient did not yet meet criteria for discharge due to persistent symptoms and risk of deterioration.
During Observation, the patient requires:
Serial vital signs and perfusion monitoring
Repeat pain reassessments and mobility evaluation
Monitoring of urine output and hydration tolerance
Trending of renal function and electrolytes
Monitoring for signs of infection or sepsis
Reassessment for need for urology consultation
Response evaluation to analgesics, antiemetics, and hydration
Education on stone passage expectations, straining urine, and return precautions
Observation remains the safest and most appropriate level of care due to the risk of obstruction, renal impairment, sepsis, dehydration, and worsening pain without continued monitoring and treatment.
Hematuria
Critical Care Time:
I provided ___ minutes of non-concurrent critical care time. This excludes separately billable procedures. Time included bedside management, reassessments, review of diagnostics, documentation, and communication with parents and staff.
Reason for Critical Care
The patient presented with signs and symptoms concerning for an acute GI bleed, including hematemesis, melena, hematochezia, syncope, tachycardia, hypotension, pallor, dizziness, and/or abdominal pain. GI bleeding poses an imminent risk of shock, hemodynamic collapse, anemia requiring transfusion, and death, and necessitated high-level, time-sensitive medical decision making. Critical care time was required due to high risk of acute deterioration.
Critical Care Interventions Performed
I personally provided the following critical care interventions:
Continuous cardiac, respiratory, and pulse oximetry monitoring
Establishment of IV access (including second large-bore IV if needed)
Aggressive IV fluid resuscitation with crystalloid boluses
Serial blood pressure and hemodynamic monitoring
Frequent reassessments for perfusion status and mental status
Interpretation of diagnostic studies including:
CBC, CMP, magnesium, phosphorus
PT/INR, PTT
Type & screen / type & cross
Lactate
Stool occult blood
Interpretation of EKG for arrhythmias or ischemia
Interpretation of imaging (CT abdomen/pelvis or CTA if obtained)
Assessment for need for blood transfusion
Evaluation of anticoagulant use and reversal requirements
Administration of medications as indicated:
Proton pump inhibitor (IV pantoprazole)
Antiemetics
Octreotide if upper GI or variceal bleed suspected
Antibiotics if variceal bleed suspected
Monitoring for signs of worsening shock or hemodynamic instability
Consultation with gastroenterology or hospitalist regarding possible transfer or admission
Extensive counseling with patient/family regarding severity, treatment plan, and potential need for higher level of care
Observation Note
The patient was placed into Observation status due to ongoing clinical concern related to hematuria, requiring continued monitoring, diagnostic clarification, hydration assessment, and serial reassessments before a safe discharge determination could be made. At the time Observation was initiated, the patient did not yet meet criteria for discharge due to persistent symptoms and risk of deterioration.
During Observation, the patient requires:
Serial vital signs and perfusion assessments
Repeat evaluation of urine output and color change
Trending renal function and laboratory abnormalities
Monitoring for fever, infection progression, worsening pain
Reassessment for potential stone passage
Determination of need for urology consultation
Monitoring response to hydration and medications
Patient education on return precautions and follow-up
Observation remains the safest and most appropriate level of care due to the risk of urinary obstruction, renal impairment, bleeding progression, infection, and potential clinical deterioration without continued monitoring and treatment.
Possible Pylonephritis
Critical Care Time:
I provided ___ minutes of non-concurrent critical care time. This excludes separately billable procedures. Time included bedside management, reassessments, review of diagnostics, documentation, and communication with parents and staff.
Reason for Critical Care
The patient presented with flank pain, fever, chills, dysuria, nausea/vomiting, tachycardia, hypotension, and/or altered mentation, raising concern for pyelonephritis with risk of progression to sepsis, septic shock, renal injury, or bacteremia. Due to the possibility of rapid clinical deterioration and multi-organ involvement, the patient required critical care-level evaluation and management.
Critical Care Interventions Performed
Continuous cardiac and oxygen saturation monitoring
Serial vital signs and perfusion assessments
Establishment of IV access
IV fluid resuscitation
Administration of antipyretics and antiemetics
Initiation of IV antibiotics per suspected organism/severity
Interpretation of diagnostic studies including: CBC, CMP, magnesium, phosphorus, Lactate, UA and urine culture
Blood cultures
Pregnancy test if applicable
Interpretation of imaging:
CT Abdomen/Pelvis or renal ultrasound to evaluate for obstruction, stone, or abscess
Evaluation for:
Hemodynamic instability
Acute kidney injury
Persistent tachycardia
Hypotension
Altered mental status
Sepsis screening and management pathway if indicated
Coordination with hospitalist/urology if obstruction or severe infection suspected
Clear communication with nursing regarding escalation triggers
Counseling patient/family regarding diagnosis, severity, risks, and treatment plan
Ongoing reassessments to monitor for deterioration
Observation Note
The patient was placed into Observation status due to ongoing clinical concern for possible pyelonephritis, requiring continued monitoring, diagnostic clarification, IV treatment response evaluation, and serial examinations prior to determining safe discharge. At the time Observation was initiated, the patient did not yet meet criteria for discharge due to persistent symptoms and risk of clinical deterioration.
During Observation, the patient requires:
Serial vital signs and perfusion assessments
Repeat evaluation for fever, tachycardia, or worsening CVA tenderness
Trending renal function and laboratory abnormalities
Monitoring for urine output and hydration tolerance
Reassessment for need for urology or hospital admission
Monitoring response to IV antibiotics and supportive therapy
Patient education on infection indicators and return precautions
Observation remains the safest and most appropriate level of care due to the risk of worsening infection, renal impairment, sepsis progression, and clinical decline without continued monitoring and treatment.
Vaginal Bleeding (Pregnant)
Critical Care Time:
I provided ___ minutes of non-concurrent critical care time. This excludes separately billable procedures. Time included bedside management, reassessments, review of diagnostics, documentation, and communication with parents and staff.
Reason for Critical Care
The patient presented with vaginal bleeding during pregnancy, raising immediate concern for multiple life-threatening maternal and fetal conditions, including ectopic pregnancy with risk of rupture, threatened or incomplete miscarriage, placenta previa, placental abruption, uterine hemorrhage, severe anemia, hemorrhagic shock, septic miscarriage, chorioamnionitis, or other emergent obstetric complications. Given the risk of maternal hemorrhage, hemodynamic collapse, fetal compromise or demise, coagulopathy, infection progression, airway compromise, or death, the patient required critical care–level evaluation, monitoring, and treatment. Critical care time was medically necessary.
Critical Care Interventions Performed
Critical care management included:
Continuous cardiac, hemodynamic, and oxygen monitoring
Serial vital signs with frequent perfusion assessments
Serial abdominal and pelvic examinations
Establishment of IV access
IV fluid resuscitation for bleeding or hypotension
Pain control and antiemetic therapy
Antibiotics if septic miscarriage or infection suspected
Magnesium sulfate if preeclampsia/eclampsia concern
Diagnostic studies reviewed and interpreted:
CBC for anemia or trending H/H
CMP
coagulation panel
lactate if infection suspected
quantitative hCG
type & screen
urinalysis
Imaging:
Transvaginal ultrasound to evaluate fetal viability, location, heart rate, and rule out ectopic
Pelvic ultrasound for placenta position, previa, or abruption signs
FAST exam if trauma or bleeding suspected
EKG interpretation if tachycardic, hypotensive, or symptomatic
Monitoring for:
worsening vaginal bleeding
ectopic rupture
hemodynamic instability
fetal distress (if gestational age appropriate)
Coordination with OB/GYN, maternal-fetal medicine, anesthesia, or transfer team
Extensive counseling with patient and family regarding findings and risks
Observation Note
The patient was placed into Observation status due to ongoing clinical concern related to vaginal bleeding during pregnancy, requiring continued monitoring, diagnostic clarification, and reassessment before determining whether safe discharge was appropriate. At the time Observation was initiated, the patient did not yet meet criteria for discharge due to persistent symptoms and the potential for maternal or fetal deterioration.
During Observation, the patient requires serial vital signs, repeat abdominal and pelvic exams, ongoing assessment of bleeding progression, trending of lab values, hydration monitoring, and evaluation of response to medications such as IV fluids, analgesics, antiemetics, or antibiotics (if infection suspected). The patient may also require reassessment of stability for ambulation, oral intake tolerance, and repeat ultrasound if symptoms evolve.
Observation remains the safest and most appropriate level of care due to the risk of maternal hemorrhage, pregnancy loss, ectopic rupture, or fetal compromise, and the need for continued medically supervised evaluation.
Vaginal Bleeding (Non-Pregnant)
Critical Care Time:
I provided ___ minutes of non-concurrent critical care time. This excludes separately billable procedures. Time included bedside management, reassessments, review of diagnostics, documentation, and communication with parents and staff.
Reason for Critical Care
The patient presented with vaginal bleeding while not pregnant, raising concern for multiple life-threatening gynecologic or medical emergencies, including severe uterine bleeding, fibroid-related hemorrhage, endometrial pathology, retained products of conception (if recent pregnancy), pelvic infection/sepsis, coagulopathy (including anticoagulant-related bleeding or DIC), severe anemia, ovarian torsion, or internal hemorrhage.
Given the risk of hemodynamic instability, shock, worsening hemorrhage, acute blood loss anemia, infection progression, organ dysfunction, or death, the patient required critical care–level evaluation, monitoring, and treatment. Critical care time was medically necessary.
Critical Care Interventions Performed
Critical care management included:
Continuous cardiac, hemodynamic, and oxygen monitoring
Serial vital signs and perfusion checks
Establishment of IV access
IV fluid resuscitation for blood loss or hypotension
Type & screen / crossmatch for potential transfusion
Pain control and antiemetics
Holding anticoagulants when medically appropriate
Medication management depending on condition:
Tranexamic acid (TXA)
Hormonal therapy per OB/GYN recommendation
Antibiotics if infection suspected
Diagnostic studies reviewed and interpreted:
CBC for anemia or active blood loss
CMP
coagulation panel
lactate if shock suspected
pregnancy test to confirm non-pregnant status
urinalysis if infection suspected
Imaging:
Pelvic ultrasound (transabdominal or transvaginal)
CT abdomen/pelvis if concern for alternative pathology
EKG interpretation for tachycardia or arrhythmia related to anemia/shock
Monitoring for:
increasing bleeding
hemodynamic instability
worsening pelvic pain
signs of sepsis or infection
Frequent reassessments of bleeding amount, vitals, pallor, perfusion, and pain
Coordination with OB/GYN, interventional radiology if needed, or transfer center
Patient/family counseling regarding findings and treatment plan
Observation Note
The patient was placed into Observation status due to ongoing clinical concern related to vaginal bleeding in a non-pregnant patient, requiring continued monitoring, diagnostic clarification, serial examinations, and evaluation of treatment response prior to determining safe discharge. At the time Observation was initiated, the patient did not yet meet criteria for discharge due to persistent bleeding, evolving symptoms, and the potential for hemodynamic or clinical deterioration.
During Observation, the patient requires serial vital signs, frequent reassessment of bleeding volume, monitoring for hemodynamic instability, repeated pelvic or abdominal examinations, trending of hemoglobin/hematocrit, evaluation of hydration status, and monitoring for syncope or worsening anemia. The patient also requires reassessment of response to medications, need for further imaging or OB/GYN intervention, and evaluation of safe ambulation and oral intake before discharge.
Observation remains the safest and most appropriate level of care due to the risk of worsening hemorrhage, hemodynamic instability, severe anemia, infection, or need for procedural intervention, and the need for continued medically supervised evaluation.
Possible Ectopic
Critical Care Time:
I provided ___ minutes of non-concurrent critical care time. This excludes separately billable procedures. Time included bedside management, reassessments, review of diagnostics, documentation, and communication with parents and staff.
Reason for Critical Care
The patient presented with symptoms concerning for a possible ectopic pregnancy, a life-threatening condition associated with tubal rupture, massive intra-abdominal bleeding, hemorrhagic shock, severe anemia, infection, and maternal death if not promptly recognized and treated. Clinical presentation raised concern for ectopic implantation, impending rupture, early rupture, or unstable early pregnancy of unknown location.
Given the risk of rapid hemodynamic collapse, airway compromise, worsening abdominal bleeding, severe pain, and fetal non-viability, the patient required critical care–level evaluation, monitoring, and resuscitation. Critical care time was medically necessary.
Critical Care Interventions Performed
Critical care management included:
Continuous cardiac, respiratory, and pulse oximetry monitoring
Serial vital signs with focus on perfusion status
Serial abdominal exams for worsening tenderness, guarding, rigidity
Establishment of IV access
Aggressive IV fluid resuscitation for suspected blood loss
Preparation for blood transfusion (type & screen / crossmatch ordered)
Pain management and antiemetics
Antibiotics if infection suspected
Diagnostic studies reviewed and interpreted:
CBC for anemia or active blood loss
CMP
Coagulation studies
Quantitative hCG
Lactate if hypotension or infection suspected
Urinalysis
Urgent transvaginal ultrasound for:
location of pregnancy
presence or absence of intrauterine gestation
adnexal mass
free fluid or hemoperitoneum
FAST exam if unstable
EKG interpretation for tachycardia or hemodynamic strain
Monitoring for:
worsening abdominal pain
hypotension or tachycardia
dropping hemoglobin
signs of tubal rupture
Coordination with OB/GYN for possible:
methotrexate treatment
laparoscopic evaluation
emergent surgical intervention
transfer to higher level of OB care
Frequent reassessments of bleeding, pain, vital signs, alertness, and perfusion
Counseling of patient/family regarding severity and possible need for emergent intervention
Observation Note
The patient was placed into Observation status due to ongoing clinical concern for a possible ectopic pregnancy, a high-risk condition that can rapidly progress to tubal rupture, massive intra-abdominal hemorrhage, hemodynamic instability, and maternal life-threatening deterioration. At the time Observation was initiated, the patient did not yet meet criteria for discharge due to unresolved symptoms, pending diagnostics, and the potential for sudden clinical worsening.
During Observation, the patient requires serial vital signs, frequent abdominal and pelvic reassessments, trending of hemoglobin/hematocrit, monitoring of bleeding volume, reassessment of pain control, hydration evaluation, and review of diagnostic results as they return. The patient may also need reassessment of stability for ambulation, monitoring for worsening orthostatic symptoms, and evaluation for potential emergent surgical intervention.
Observation remains the safest and most appropriate level of care given the risk of ectopic rupture, hemorrhage, shock, and the need for ongoing medically supervised evaluation while diagnostic clarification is underway.
Medical Withdrawal Stabilization (MWS)
Alcohol Withdrawal
Critical Care Time:
I provided ___ minutes of non-concurrent critical care time. This excludes separately billable procedures. Time included bedside management, reassessments, review of diagnostics, documentation, and communication with parents and staff.
Reason for Critical Care
The patient presented with alcohol dependence requiring medical withdrawal stabilization, with high risk for severe withdrawal, seizures, delirium tremens, autonomic instability, respiratory compromise, and death. Due to the immediate risk of deterioration and the need for aggressive medical management, the patient required critical care-level evaluation and treatment.
Critical care time was medically necessary.
Critical Care Interventions Performed
Critical care management included:
Continuous cardiac, hemodynamic, and oxygen monitoring
Serial CIWA assessments and neurologic checks
Establishment of IV access
IV fluid resuscitation
Administration of:
Benzodiazepines
Thiamine prior to glucose
Folic acid + multivitamin (banana bag)
Electrolyte repletion (Mg, K, Phos)
Antiemetics
Anticonvulsants if needed
Interpretation of diagnostic studies:
CBC, CMP
Magnesium, phosphorus
Glucose
Alcohol level
Pregnancy test if applicable
EKG interpretation
Evaluation for:
seizures
hallucinations
respiratory decline
hepatic encephalopathy
arrhythmias
Safety precautions including seizure and fall precautions
Assessment for comorbid infection or trauma
Counseling patient/family regarding risks, severity, and treatment plan
Coordination with detox/rehab resources and placement planning
Ongoing reassessments and medication titration based on symptoms
Observation Note
The patient was placed into Observation status due to ongoing clinical concern for alcohol withdrawal, requiring continued monitoring, medication titration, diagnostic trending, and serial assessments prior to determining safe discharge. At the time Observation was initiated, the patient did not yet meet criteria for discharge due to persistent withdrawal symptoms and the risk of rapid deterioration.
During Observation, the patient requires:
Continuous or frequent monitoring for seizures, hallucinations, or worsening withdrawal
Serial CIWA assessments and medication adjustment
Repeat electrolytes and labs to evaluate correction
Hydration and nutritional support monitoring
Reassessment for mental status changes or autonomic instability
Monitoring for respiratory depression related to withdrawal or medications
Patient counseling, education, and planning for detox/rehabilitation follow-up
Observation remains the safest and most appropriate level of care due to the risk of severe withdrawal, seizures, delirium tremens, electrolyte abnormalities, hemodynamic instability, and potential life-threatening deterioration without continued medical monitoring and treatment.
Benzodiazipine Withdrawal
Critical Care Time:
I provided ___ minutes of non-concurrent critical care time. This excludes separately billable procedures. Time included bedside management, reassessments, review of diagnostics, documentation, and communication with parents and staff.
Reason for Critical Care
The patient presented with benzodiazepine dependence requiring medical withdrawal stabilization, with high risk for seizures, status epilepticus, autonomic instability, severe agitation, delirium, respiratory compromise, and death. Benzodiazepine withdrawal poses a life-threatening medical emergency, particularly after chronic or high-dose use. Due to the immediate risk of neurologic and cardiopulmonary decline, the patient required critical care-level evaluation, monitoring, and treatment. Critical care time was medically necessary.
Critical Care Interventions Performed
Critical care management included:
Continuous cardiac, hemodynamic, and oxygen monitoring
Serial CIWA assessments and neurologic checks
Establishment of IV access
IV fluid resuscitation
Administration of:
Benzodiazepines
Thiamine prior to glucose
Folic acid + multivitamin (banana bag)
Electrolyte repletion (Mg, K, Phos)
Antiemetics
Anticonvulsants if needed
Interpretation of diagnostic studies:
CBC, CMP
Magnesium, phosphorus
Glucose
Alcohol level
Pregnancy test if applicable
EKG interpretation
Evaluation for:
seizures
hallucinations
respiratory decline
hepatic encephalopathy
arrhythmias
Safety precautions including seizure and fall precautions
Assessment for comorbid infection or trauma
Counseling patient/family regarding risks, severity, and treatment plan
Coordination with detox/rehab resources and placement planning
Ongoing reassessments and medication titration based on symptoms
Observation Note
The patient was placed into Observation status due to ongoing clinical concern for benzodiazepine withdrawal, requiring continued monitoring, medication titration, diagnostic trending, and serial assessments before determining safe discharge. At the time Observation was initiated, the patient did not yet meet criteria for discharge due to ongoing symptoms and a high risk of sudden deterioration.
During Observation, the patient requires:
Serial neurologic and mental status checks
Frequent withdrawal scoring and medication titration
Continuous or frequent vital sign monitoring
Repeat labs to trend electrolyte correction
Monitoring for hallucinations, confusion, or agitation
Evaluation for seizures or worsening withdrawal
Hydration and nutritional support
Patient counseling and coordination of detox or rehab placement
Observation remains the safest and most appropriate level of care at this time due to the risk of severe benzodiazepine withdrawal, seizures, delirium, respiratory compromise, autonomic instability, and potential for life-threatening deterioration without continued medical supervision.
Opioid Withdrawal
Critical Care Time:
I provided ___ minutes of non-concurrent critical care time. This excludes separately billable procedures. Time included bedside management, reassessments, review of diagnostics, documentation, and communication with parents and staff.
Reason for Critical Care
The patient presented with opioid dependence requiring medical withdrawal stabilization, with risk for severe withdrawal, dehydration, electrolyte abnormalities, autonomic instability, aspiration, acute psychiatric distress, and potential for respiratory compromise due to co-ingestants or concurrent conditions. Due to the risk of rapid deterioration, the patient required critical care-level monitoring, medication management, and diagnostic evaluation. Critical care time was medically necessary.
Critical Care Interventions Performed
Critical care management included:
Continuous cardiac, hemodynamic, and oxygen monitoring
Serial withdrawal assessments (e.g., COWS scoring)
Establishment of IV access
Administration of:
Clonidine for autonomic symptoms
Antiemetics
Antidiarrheals
NSAIDs/analgesics for body aches
IV fluids for dehydration
Electrolyte replacement (K, Mg, Phos)
Interpretation of diagnostic studies:
CBC, CMP
Electrolytes (K, Mg, Phos)
CK if severe agitation or pain
Glucose
Urinalysis
Pregnancy test if applicable
EKG interpretation for QTc prolongation or arrhythmia
Evaluation for co-ingestants or polysubstance effects
Continuous reassessment to evaluate for:
worsening autonomic instability
dehydration
severe agitation
respiratory compromise
altered mental status
Seizure, fall, and aspiration precautions
Counseling patient/family on withdrawal course, treatment plan, and recovery resources
Coordination with detox/rehab programs or outpatient follow-up
Observation Note
The patient was placed into Observation status due to ongoing clinical concern for opioid withdrawal, requiring continued monitoring, medication titration, hydration support, diagnostic trending, and serial assessments prior to determining safe discharge. At the time Observation was initiated, the patient did not yet meet criteria for discharge due to persistent symptoms and risk of deterioration.
During Observation, the patient requires:
Serial withdrawal scoring (COWS)
Monitoring of vital signs and autonomic stability
Repeated hydration and electrolyte reassessment
Frequent symptom reassessments to titrate medications
Monitoring for respiratory depression if sedating agents given
Evaluation for safety and stabilization
Patient education on withdrawal, and follow-up care
Coordinated planning for detox/rehab or outpatient treatment
Observation remains the safest and most appropriate level of care due to the risk of autonomic instability, dehydration, electrolyte abnormalities, cardiac complications, psychiatric distress, and potential life-threatening deterioration without continued medical supervision.
Stimulant Withdrawal
Critical Care Time:
I provided ___ minutes of non-concurrent critical care time. This excludes separately billable procedures. Time included bedside management, reassessments, review of diagnostics, documentation, and communication with parents and staff.
Reason for Critical Care
The patient presented with symptoms consistent with acute stimulant intoxication and/or stimulant withdrawal, associated with high risk for cardiac dysrhythmia, hypertensive emergency, myocardial ischemia, hyperthermia, severe agitation, psychosis, seizures, rhabdomyolysis, and sudden death. Due to the risk of rapid physiologic and psychiatric deterioration, critical care-level monitoring, evaluation, and treatment were required.
Critical care time was medically necessary.
Critical Care Interventions Performed
Critical Care Management Included:
Continuous cardiac, hemodynamic, and pulse oximetry monitoring
Serial neurologic and mental status exams
De-escalation, redirection, and safety measures
Seizure precautions and behavioral safety monitoring
Establishment of IV access
Administration of:
Benzodiazepines for agitation, hypertension, tachycardia
Antipsychotics if severe psychosis
IV fluids for dehydration or rhabdomyolysis prevention
Banana bag (thiamine, folic acid, multivitamin) to address nutritional deficiency risk and prevent Wernicke’s encephalopathy
Electrolyte replacement (K, Mg, Phos)
Cooling measures for hyperthermia
Interpretation of diagnostic studies:
CBC, CMP
CK for rhabdomyolysis
Electrolytes (K, Mg, Phos)
Troponin if chest pain or dysrhythmia
Urine drug screen
Glucose
EKG interpretation for QRS/QTc prolongation or ischemia
Temperature monitoring and management
Evaluation for:
chest pain source
neurologic deficits
dehydration or rhabdo
psychosis or suicidal ideation
Coordination with behavioral health, addiction services, and detox resources
Frequent reassessing of vitals, agitation level, mental status, and cardiac status
Observation Note
The patient was placed into Observation status due to ongoing clinical concern for acute stimulant intoxication and/or withdrawal, requiring continued monitoring, diagnostic trending, medication titration, and serial reassessments prior to determining safe discharge. At the time Observation was initiated, the patient did not yet meet criteria for discharge due to persistent symptoms and risk of rapid deterioration.
During Observation, the patient requires:
Frequent vital sign and cardiac monitoring
Cooling, hydration, and magnesium/potassium trending
Monitoring for worsening psychosis, paranoia, or hallucinations
Serial CK and renal function checks to evaluate rhabdomyolysis risk
Monitoring for chest pain, arrhythmias, or neurologic symptoms
Coordination with behavioral health and substance use treatment services
Education and discharge planning once medically stable.
Observation remains the safest and most appropriate level of care due to the risk of arrhythmia, hypertensive crisis, seizure, hyperthermia, rhabdomyolysis, and potential for sudden life-threatening deterioration without continued supervised medical management.
Neurologic
Altered Mental Status
Critical Care Time:
I provided ___ minutes of non-concurrent critical care time. This excludes separately billable procedures. Time included bedside management, reassessments, review of diagnostics, documentation, and communication with parents and staff.
Reason for Critical Care
The patient presented with Altered Mental Status (AMS) with concern for imminent life-threatening deterioration. Differential included stroke, sepsis, hypoxia, hyper/hypoglycemia, electrolyte disturbance, overdose, withdrawal, intracranial hemorrhage, meningitis/encephalitis, intoxication, metabolic crisis, and other emergent conditions. Due to the risk of airway compromise, respiratory failure, aspiration, seizure, cardiac instability, neurologic deterioration, or death, the patient required critical care-level monitoring, diagnostic evaluation, and intervention. Critical care time was medically necessary.
Critical Care Interventions Performed
Critical care management included:
Continuous cardiac, respiratory, and pulse oximetry monitoring
Serial neurologic exams including GCS
Airway assessment and aspiration precautions
Seizure precautions
Establishment of IV access
Administration of:
IV fluids for perfusion support
Glucose correction if needed
Naloxone if opioid intoxication suspected
Electrolyte correction (Na, K, Mg, Ca, Phos)
Antibiotics if concern for infection/sepsis
Diagnostic studies reviewed and interpreted:
CBC, CMP
Glucose
Electrolytes
Magnesium, phosphorus
ABG or VBG
Urine drug screen
Urinalysis
Troponin if indicated
Pregnancy test if applicable
EKG interpretation for ischemia, arrhythmia, or QT abnormality
Imaging:
Head CT if indicated (stroke, trauma, acute neuro change)
Chest X-ray if infection or hypoxia suspected
Temperature monitoring and management
Stroke evaluation if applicable
Frequent reassessments of mental status, airway, vitals
Coordination with:
Neurology
Poison control (if applicable)
Family/caregivers
Continuous reevaluation for escalation to higher-level care
Observation Note
The patient was placed into Observation status due to ongoing clinical concern for Altered Mental Status, requiring continued monitoring, diagnostic clarification, serial neurologic assessments, and treatment response evaluation. At the time Observation was initiated, the patient did not yet meet criteria for discharge due to persistent symptoms and risk of clinical deterioration.
During Observation, the patient requires:
Continuous or frequent monitoring of mental status and vitals
Serial neurologic rechecks
Repeat glucose and electrolyte trending
Ongoing evaluation for developing stroke, intoxication/withdrawal, or metabolic crisis
Monitoring for respiratory compromise or aspiration
Coordination with neurology, psychiatry, or other services as needed
Reevaluation of imaging and labs as results finalize
Education of family/caregivers regarding findings and plan
Observation remains the safest and most appropriate level of care due to the risk of neurologic, metabolic, respiratory, or toxicologic deterioration and the need for continued supervised medical evaluation.
Dizziness/Syncope
Critical Care Time:
I provided ___ minutes of non-concurrent critical care time. This excludes separately billable procedures. Time included bedside management, reassessments, review of diagnostics, documentation, and communication with parents and staff.
Reason for Critical Care
The patient presented with dizziness / near syncope / syncope, raising concern for immediate life-threatening conditions, including cardiac dysrhythmia, myocardial ischemia, stroke/TIA, intracranial hemorrhage, severe dehydration, electrolyte derangements, sepsis, anemia, or toxicologic/metabolic crisis. Given the risk of sudden cardiac arrest, neurologic deterioration, airway compromise, hemodynamic collapse, or death, the patient required critical care-level evaluation, monitoring, and treatment. Critical care time was medically necessary.
Critical Care Interventions Performed
Critical care management included:
Continuous cardiac, hemodynamic, and pulse oximetry monitoring
Serial neurologic assessments and stroke screening
Establishment of IV access
Fluid resuscitation
Electrolyte correction (K, Mg, Ca, Na, Phos)
Medication administration as indicated:
Antiarrhythmics
Nitroglycerin or aspirin if ischemia suspected
Antiemetics
Orthostatic vital sign assessment
Interpretation of diagnostic studies:
CBC, CMP
Electrolytes
Magnesium, phosphorus
Troponin
Glucose
Urinalysis
Pregnancy test if applicable
EKG interpretation for arrhythmia, ischemia, QT prolongation, heart block
Imaging:
Chest X-ray
CT head if neurologic deficit, trauma, or atypical presentation
Cardiac monitoring for ongoing arrhythmia detection
Temperature monitoring
High-risk evaluation for:
stroke/TIA
PE (history, exam, risk factors considered)
Frequent reassessment for recurrence of syncope, dizziness, hypotension, or neuro decline
Coordination with cardiology, neurology, or hospitalist if needed
Counseling patient/family on findings and risk
Observation Note
The patient was placed into Observation status due to ongoing clinical concern for Altered Mental Status, requiring continued monitoring, diagnostic clarification, serial neurologic assessments, and treatment response evaluation. At the time Observation was initiated, the patient did not yet meet criteria for discharge due to persistent symptoms and risk of clinical deterioration.
During Observation, the patient requires:
Continuous or frequent monitoring of mental status and vitals
Serial neurologic rechecks
Repeat glucose and electrolyte trending
Ongoing evaluation for developing stroke, intoxication/withdrawal, or metabolic crisis
Monitoring for respiratory compromise or aspiration
Coordination with neurology, psychiatry, or other services as needed
Reevaluation of imaging and labs as results finalize
Education of family/caregivers regarding findings and plan
Observation remains the safest and most appropriate level of care due to the risk of neurologic, metabolic, respiratory, or toxicologic deterioration and the need for continued supervised medical evaluation.
Headache
Critical Care Time:
I provided ___ minutes of non-concurrent critical care time. This excludes separately billable procedures. Time included bedside management, reassessments, review of diagnostics, documentation, and communication with parents and staff.
Reason for Critical Care
The patient presented with a severe headache, which raised concern for multiple life-threatening conditions, including subarachnoid hemorrhage, intracranial hemorrhage, meningitis or encephalitis, stroke or TIA, hypertensive emergency, temporal arteritis, cerebral venous thrombosis, mass effect or increased intracranial pressure, carbon monoxide exposure, and other toxicologic or metabolic emergencies. Given the significant risk of neurologic deterioration, airway compromise, seizure, herniation, or death, the patient required critical care–level evaluation, monitoring, and treatment. Critical care time was medically necessary.
Critical Care Interventions Performed
Critical care management included:
Continuous cardiac, hemodynamic, and pulse oximetry monitoring
Serial neurologic exams
Blood pressure monitoring for hypertensive emergency
Establishment of IV access
Administration of:
IV fluids
Antiemetics
Analgesics
Antihypertensives if indicated
Dexamethasone if meningitis or mass effect considered
Magnesium if migraine-related
Diagnostic studies reviewed and interpreted:
CBC, CMP
Electrolytes, glucose
Coagulation panel
ESR/CRP if temporal arteritis suspected
Urine drug screen
Pregnancy test if applicable
Neuroimaging:
CT head without contrast
CTA head/neck if aneurysm or dissection suspected
EKG interpretation for hypertensive emergency or cardiac involvement
Strict monitoring for:
worsening neuro deficits
seizure activity
signs of meningitis
ICP changes
Airway assessment and aspiration precautions
Temperature monitoring
Coordination with neurology, neurosurgery, or infectious disease as needed
Patient/family counseling regarding diagnostic findings and plan
Observation Note
The patient was placed into Observation status due to ongoing clinical concern related to a severe or undifferentiated headache, requiring continued monitoring, diagnostic clarification, serial neurologic examinations, and treatment response evaluation before a safe discharge determination could be made. At the time Observation was initiated, the patient did not yet meet criteria for discharge due to persistent symptoms and the potential for clinical deterioration.
During Observation, the patient requires ongoing clinical monitoring, which includes repeated neurologic examinations, continuous trending of vital signs, evaluation of hydration status, and review of imaging or laboratory results as they finalize. The patient also needs ongoing reassessment of treatment effectiveness, with close monitoring for any adverse reactions or signs of clinical worsening.
Observation remains the safest and most appropriate level of care at this time due to the risk of neurologic deterioration, uncontrolled symptoms, and the need for continued supervised medical evaluation.
Stroke
Critical Care Time:
I provided ___ minutes of non-concurrent critical care time. This excludes separately billable procedures. Time included bedside management, reassessments, review of diagnostics, documentation, and communication with parents and staff.
Reason for Critical Care
The patient presented with acute neurologic symptoms concerning for stroke, including sudden onset of weakness, numbness, speech difficulty, facial droop, visual disturbances, dizziness, gait instability, or altered mental status. These symptoms raise immediate concern for ischemic stroke, hemorrhagic stroke, TIA, cerebral venous thrombosis, carotid/vertebral artery dissection, or other rapidly progressive neurologic emergencies. Given the risk of neurologic deterioration, cerebral edema, herniation, seizure, loss of airway protection, or death, the patient required critical care–level monitoring, rapid diagnostic evaluation, and emergent treatment decisions. Critical care time was medically necessary.
Critical Care Interventions Performed
Critical care management included:
Continuous cardiac, hemodynamic, and pulse-oximetry monitoring
Serial neurologic exams including NIH Stroke Scale
Rapid point-of-care glucose
Establishment of IV access
Blood pressure management
Airway assessment and aspiration precautions
Administration of:
IV fluids if indicated
Antiemetics
Antihypertensives only if clinically appropriate for stroke protocol
Diagnostic studies reviewed and interpreted:
CBC, CMP
electrolytes and glucose
coagulation panel
troponin
pregnancy test if applicable
urine drug screen
Neuroimaging:
CT head without contrast
CTA head/neck to assess for LVO or dissection
EKG interpretation for arrhythmia or QT abnormalities
Evaluation for:
need for neurology or neurosurgery consultation
Frequent reassessment for worsening neurologic deficits.
Counseling of patient/family regarding critical findings, need for imaging, and treatment options
Weakness
Critical Care Time:
I provided ___ minutes of non-concurrent critical care time. This excludes separately billable procedures. Time included bedside management, reassessments, review of diagnostics, documentation, and communication with parents and staff.
Reason for Critical Care
The patient presented with generalized weakness, raising concern for multiple life-threatening conditions, including stroke/TIA, intracranial hemorrhage, sepsis, electrolyte abnormalities, acute anemia, myocardial ischemia, arrhythmia, metabolic crisis, toxicologic exposure, neuromuscular disease, and respiratory failure. Given the risk of neurologic deterioration, cardiac instability, respiratory compromise, severe dehydration, metabolic derangement, or death, the patient required critical care–level evaluation, monitoring, and treatment. Critical care time was medically necessary.
Critical Care Interventions Performed
Critical care management included:
Continuous cardiac, hemodynamic, and oxygen monitoring
Serial neurologic exams
Establishment of IV access
IV fluid resuscitation for perfusion or dehydration
Electrolyte replacement
Glucose correction if hypoglycemic
Antiemetics for nausea/vomiting
Benzodiazepines if withdrawal risk
Antibiotics if infection suspected
Diagnostic studies reviewed and interpreted:
CBC, CMP
electrolytes
glucose
magnesium, phosphorus
troponin
urinalysis
TSH
pregnancy test if applicable
urine drug screen
EKG interpretation for ischemia, arrhythmia, QT prolongation
Imaging as indicated:
CT head
chest X-ray
Temperature monitoring
Orthostatic vital assessment
Evaluation for respiratory decline or need for airway support
Coordination with neurology, cardiology, or hospitalist as needed
Frequent reassessment of strength, vitals, sensory deficits, hydration status, and overall stability
Observation Note
The patient was placed into Observation status due to ongoing clinical concern related to generalized weakness, requiring continued monitoring, diagnostic clarification, serial examinations, and evaluation of treatment response before safe discharge could be determined. At the time Observation was initiated, the patient did not yet meet criteria for discharge due to persistent symptoms and the potential for clinical deterioration.
Observation remains the safest and most appropriate level of care at this time due to the risk of worsening weakness, falls, metabolic instability, neurologic progression, and the need for continued medically supervised assessment.
Fever/Sepsis
Critical Care Time:
I provided ___ minutes of non-concurrent critical care time. This excludes separately billable procedures. Time included bedside management, reassessments, review of diagnostics, documentation, and communication with parents and staff.
Reason for Critical Care
The patient presented with fever and systemic symptoms concerning for sepsis, raising concern for serious underlying conditions including bacteremia, pneumonia, urinary tract infection/pyelonephritis, meningitis, intra-abdominal infection, skin/soft tissue infection, or other sources of systemic infection. These conditions place the patient at risk for hemodynamic collapse, respiratory failure, organ dysfunction, worsening infection, septic shock, or death. Critical care time was medically necessary.
Critical Care Interventions Performed
Critical care management included:
Continuous cardiac, respiratory, and pulse oximetry monitoring
Serial vital signs and perfusion assessments
Sepsis screening and frequent reassessments
Establishment of IV access
Fluid resuscitation for possible sepsis-induced hypoperfusion
Broad-spectrum IV antibiotics initiated promptly
Antipyretics for fever management
Electrolyte replacement (K, Mg, Phos) as indicated
Vasopressor preparedness if hypotension developed (with close monitoring)
Diagnostic studies reviewed and interpreted:
CBC with differential
CMP
lactate level
magnesium/phosphorus
urinalysis and urine culture
blood cultures ×2
chest X-ray
pregnancy test if applicable
rapid viral testing (COVID/flu)
EKG interpretation for tachycardia, arrhythmia, ischemia
Imaging as indicated, including:
CT abdomen/pelvis
CT chest
CT head if AMS present
Airway assessment and aspiration precautions
Temperature monitoring
Evaluation for organ dysfunction including renal, respiratory, and hepatic involvement
Coordination with infectious disease, hospitalist, or critical care as needed
Counseling with patient/family regarding severity of illness and treatment plan
Observation Note
The patient was placed into Observation status due to ongoing clinical concern for fever and suspected sepsis, requiring continued monitoring, diagnostic clarification, serial examinations, and evaluation of treatment response prior to determining safe discharge. At the time Observation was initiated, the patient did not yet meet criteria for discharge due to persistent symptoms and the potential for clinical deterioration.
Observation remains the safest and most appropriate level of care due to the risk of progression to sepsis, hemodynamic collapse, organ dysfunction, and the need for continued medically supervised reassessment.
Trauma
Critical Care Time:
I provided ___ minutes of non-concurrent critical care time. This excludes separately billable procedures. Time included bedside management, reassessments, review of diagnostics, documentation, and communication with parents and staff.
Reason for Critical Care
The patient presented following trauma, raising concern for multiple life-threatening injuries, including intracranial hemorrhage, skull fracture, cervical spine injury, pneumothorax, hemothorax, pulmonary contusion, aortic injury, abdominal internal bleeding, solid organ injury, pelvic fracture, long-bone fracture with vascular compromise, spinal cord injury, or hemorrhagic shock. Given the risk of airway compromise, respiratory failure, hemorrhage, neurologic deterioration, shock, or death, the patient required critical care–level evaluation, monitoring, and treatment. Critical care time was medically necessary.
Critical Care Interventions Performed
Critical care management included:
Primary survey (ABCs) with airway, breathing, and circulation assessment
Continuous cardiac, respiratory, and pulse-oximetry monitoring
Serial neurologic exams
C-spine stabilization as indicated
Establishment of IV access
IV fluids for perfusion support
Pain control and antiemetics
Wound care, hemostasis, and bleeding control
Diagnostic studies reviewed and interpreted:
CBC, CMP
electrolytes
lactate
coagulation panel
type & screen
pregnancy test if applicable
Imaging:
CT head
CT cervical spine
CT chest/abdomen/pelvis (trauma protocol)
X-rays of injured areas
FAST ultrasound
EKG interpretation for arrhythmia or cardiac injury
Monitoring for:
shock
respiratory compromise
neurologic deterioration
internal bleeding
compartment syndrome
Temperature monitoring
Tetanus update if indicated
Consideration for trauma surgery or neurosurgery consultation
Frequent reassessments of vitals, perfusion, neurologic status, and injury progression
Education and communication with patient/family due to severity of illness
Observation Note
The patient was placed into Observation status due to ongoing clinical concern following a traumatic injury, requiring continued monitoring, diagnostic clarification, serial examinations, and evaluation of treatment response before a safe discharge could be determined. At the time Observation was initiated, the patient did not yet meet criteria for discharge due to persistent symptoms, potential delayed complications, and the risk of clinical deterioration.
Observation remains the safest and most appropriate level of care due to the risk of delayed traumatic injury progression, hemodynamic instability, neurologic deterioration, and the need for continued supervised medical evaluation.
Suicidal Ideation
Critical Care Time:
I provided ___ minutes of non-concurrent critical care time. This excludes separately billable procedures. Time included bedside management, reassessments, review of diagnostics, documentation, and communication with parents and staff.
Reason for Critical Care
The patient presented with active suicidal ideation, expressing thoughts, intent, or plans of self-harm. This raised immediate concern for self-inflicted injury, suicide attempt, overdose, violence toward self, impaired judgment, psychiatric crisis, or medical complications related to prior attempts or intoxication. Given the risk of imminent self-harm, loss of airway or respiratory compromise from potential overdose, cardiovascular instability from substances, acute psychosis, or death, the patient required critical care–level evaluation, monitoring, and intervention. Critical care time was medically necessary.
Critical Care Interventions Performed
Critical care management included:
Continuous cardiac, respiratory, and pulse oximetry monitoring
Placement under 1:1 direct observation for safety
Room safety modifications (removal of sharps, cords, personal belongings as required)
Serial mental status and behavior assessments
Establishment of IV access
Medical stabilization for potential ingestion, intoxication, withdrawal, or trauma
Diagnostic studies reviewed and interpreted:
CBC, CMP
electrolytes
glucose
magnesium/phosphorus
urine drug screen
serum acetaminophen/salicylate levels if ingestion suspected
pregnancy test if applicable
EKG for arrhythmia risk or QT prolongation
Temperature monitoring
Administration of medications as clinically appropriate:
benzodiazepines for agitation or possible withdrawal
antipsychotics for acute psychosis or severe agitation
IV fluids for dehydration or intoxication
Suicide risk evaluation using standardized tools
Assessment for coexisting medical emergencies (hypoglycemia, infection, intoxication, trauma, withdrawal)
Coordination with psychiatry/behavioral health, crisis team, and security
Counseling with patient regarding safety and treatment
Communication with family or support persons as appropriate
Preparation for psychiatric admission, transfer, or involuntary hold if indicated
Observation Note
The patient was placed into Observation status due to ongoing clinical concern related to suicidal ideation, requiring continued monitoring, diagnostic clarification, safety evaluation, and stabilization before a safe disposition could be determined. At the time Observation was initiated, the patient did not yet meet criteria for discharge due to persistent suicidal thoughts, impaired judgment, emotional instability, and the potential for sudden self-harm or deterioration.
Observation remains the safest and most appropriate level of care due to the unpredictable nature of suicidal crises and the need for continued medically supervised monitoring, safety precautions, and psychiatric evaluation.