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* 1. A 68-year-old male with CHF, ESRD, DM2, permanent AF, prior CVA with hemiparesis, and known nonadherence to meds including insulin and warfarin presented to the emergency room after missing last hemodialysis session. He was asymptomatic.  Blood pressure was 220/100; K was 6.3, INR 1.2, glucose 375, and INR 1.2.

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* 2. A 75-year-old woman with DM and HTN presented at 2200 to a rural hospital with unilateral vision loss.  Head CT and remainder of exam was normal.  Creatinine was 2.5 from baseline of 1.3.  Hospitalist is called for admission who recommends transfer to urban hospital due to lack of neurologist at the current hospital. ED team is insisting on at least posting orders until there is acceptance for transfer from urban hospital.

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* 3. Following up, the hospitalist starts the admission process. An admit to inpatient status order is placed and H&P is completed with plan of care to transfer to urban hospital when next bed is available. Patient is still boarding in the ED when a bed becomes available at the urban hospital. A few hours later around 0400 am, patient is transferred from the ED directly to the urban hospital without arriving on a floor unit at the rural hospital. The case is caught in your short stay self-audit process for a review if it is appropriate for an Inpatient claim.

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