#A PATIENT WITH AN ALTERED MENTAL STATUS IS HOW TO#“Most residents have never had any education on how to document from anyone other than their attending physicians. The greatest disconnect may be in that physicians are rarely, if ever, offered the opportunity to learn how to properly document or why it’s even important. The coder is extracting language to produce codes, and there is a great big disconnect between those worlds,” explains Timothy Brundage, MD, CCDS, medical director of The Brundage Group. “You read the in high-impact journals like the New England Journal of Medicine and the Annals of Internal Medicine,” says James Kennedy, MD, CCS, CDIP, CCDS, founder and president of CDIMD, a physician consulting firm.Īs a result, physicians who use the terminology that they were taught in medical school and that appears in esteemed industry journals have good reason to believe they are accurately documenting a patient’s mental state.īut many practitioners fail to realize that the language they deem commonplace does not always translate to an ICD-10 code. Indeed, physicians are using what they know to be a widely agreed-upon phrase when they note their patients’ altered mental status. “The problem is it was always a general descriptor and never provided any additional information about why they were having an altered mental status.” #A PATIENT WITH AN ALTERED MENTAL STATUS IS PROFESSIONAL#“It’s considered a much more professional way to describe someone who is flipped out,” says Victor Freeman, MD, MPP, an adjunct assistant professor in the HIM graduate department at the University of Maryland and national medical director for CDI for Nuance Communications. As a result, they’re recognizing the generic term doesn’t cut it.Īltered mental status is a phrase all medical students learn early in their education to describe patients who are in some way confused or exhibiting limited consciousness. Unfortunately, physicians are finding more occasion to document altered mental status due to the rise in Alzheimer’s disease as well as the opioid epidemic. When clinical documentation improvement (CDI) experts discover altered mental status is being used as a diagnosis within the chart, they know two things: The documenting physician is undervaluing the care he or she is delivering, and a little education is in order. However, use of the term becomes problematic when it makes its way from clinical conversation into clinical documentation. Generally speaking, the term is just fine when a physician is, well, generally speaking. Use of this generic term in clinical documentation often leads to misrepresentation of the care being provided.Īltered mental status is a phrase commonly uttered among clinicians to characterize a broad spectrum of behaviors and states of being that range from confusion to coma.
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Double decker beds are great for space-saving. Typically made of wood, the bunk bed would take on a more modern look with many becoming available in sleek metal as well. We provide the latest and widest range of double deck bunk beds and triple decker beds at affordable prices. From there, bunk beds became a mainstay in smaller homes where saving on space was crucial. Bunk beds really started to become popular when used in the military to help provide sleep space to twice as many soldiers. There isn’t a particular individual who first invented bunk beds and they are actually believed to go back to medieval times when the poor were trying to save on space. The history of bunk beds is hard to pinpoint. Suitable for: Room with low ceiling and bay window. While these beds were originally intended only for the noble and elite of society, eventually beds would become a normal concept around the world as a necessary household furniture. The Egyptians would usually make a bed frame out of wood and then fill the frame with a softer material such as cotton or feathers. While they weren’t made of completely enclosed springs like today, they were the first frame style beds. In this double decker bed, the upper bed is accessed by stairs to represent. The Egyptians were the first to start making what we think of as beds. Give your childs bedroom a classy appeal by bringing wooden bunk beds with stairs. Before this time, people would usually just sleep on the hard ground with a little hay as a buffer. The idea of a bed was first seen in ancient Egypt. Where is the starting point for the history of the bunk bed? Let’s take a closer look at the history of bunk beds! The Ireland Boys made a Double Decker Electric BED and DROVE IT This was so much fun riding an electric bed, which we made into a double decker electric bed. While bunk beds are now a staple in modern home furnishings thanks to their playful fun and the way they save on space while maximizing sleep areas, they haven’t been around forever. #Syberia ii walkthru generator(The generator will puff smoke and try to start but then fail) Take the gas container on the left, notice that it is empty. Press the button on the iron support to start the generator. Now walk towards the area farthest to the left, you should be in front of a generator. Continue to the area where you see the little girl (Malka) again. Use the stairs to go to the lower part of the village. A cutscene showing two gates opening will play. Head back to the gate near the back of the train and use the key on the lock. The cutscene with Malka and her balloon will play and will end with the key for the gate in your inventory. Once she says that she wants something give her the candies (Katalas). You should see a young girl down below in the lower village. Head back to where you used the lever for the large charcoal machine. (Katalas) Return outside to the train platform. Turn the lever of the same machine and then take the candies that fall. Use the coin of Canadian money (the caribou) on the left machine. You will now have a collection of change in your inventory. Use the candy machine key on the drawer of the machine farthest to the right. Head back to the 1st area of the store and examine the candy machines at the end of Emeliov’s counter. Take the candy machine key that is lying in the close-up. Examine the counter on the right with the broken candy machines. Click on the topics “Charcoal” and “Key”. Talk to Emiliov who should be standing behind the counter. Enter the building (General Store) straight across from the train. Return to the area where you saw Emeliov at the entrance to the passenger train. In this area there is a gate on the left. Head all the way to the back end of the train on the platform. Use the lever and watch the cutscene of the large charcoal machine arm moving. You should be standing in front of a lever, click on it. Take 1st small platform that leads to the right. Return to the previous area where we see the train from high above. Use the wind-up wheel in the center to wind the train. In the area with Oscar use the lever on the left to activate the train-winding mechanism. Make your way to front of the train near the engine and talk to Oscar. Kate then finds herself alone on the train platform. Once outside exit the area to your right. Open the door on the right that leads out of the train. After the call continue to the next area of the wagon and then open the door on your left. Click on the dialog topic “Departure” Return to the 1st wagon, continue towards the front of the train until you receive a call from Oscar the automat train operator. Syberia is famous for its climatic graphics with pre-rendered, hand-drawn backgrounds.World 1 : Romansburg Go to the back of the train and talk to Hans. Since it's a typical point-and-click adventure game, the gameplay consists mostly of exploring locations, solving riddles and speaking with non-playable characters. During the journey she will visit various climatic and mysterious places located in the Eastern Europe and she will meet many interesting people. The task pushes her to embark on the greatest adventure of her life. In order to complete her mission, Kate must find her heir. The game begins when the protagonist arrives at the factory and learns that its owner, Anna Voralberg, is dead. She is tasked with finishing the formalities related to taking over a factory located in a small city in Europe. Syberia is the first chapter of the adventures of Kate Walker, an American lawyer hired by the company that produces automatons – mechanical toys. During her adventures Kate will visit, among other places, the North-West passage and the village of the Youkol people.Īn adventure game designed by Benoit Sokal, the famous Belgian comic writer, in cooperation with studio Microids. Syberia II takes place in completely new locations that are much more different from each other than previously. Many new graphic effects were added, including dynamic shadows and an animated snow. The greatest change in comparison to the first game lies in the quality of the graphics and the increase of the gameplay dynamics. The woman joins Hans and she helps him discover the mystery of the last living Mammoths. This time Kate decides to follow the trail of Hans Voralberg, the heir to an automaton factory, for her own reasons. The game starts in the same place where the first Syberia ended – in the Russian city Romansburg. Her intention of finalizing a contract led her to the adventure of her life. Syberia II continues the plot of the first installment - it presents the further adventures of Kate Walker, an American lawyer. A sequel to the excellent adventure game created by Benoit Sokal and studio Microids.
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She does have a full character model programmed into the game (viewable in the 11th Training mission showcasing Item Capsules) and the bonus "Behind the Screams" DVD packaged with the Collectors Edition release shows her FUNimation actress Tiffany Vollmer recording battle audio (which isn't present on the disc). Gero is a more important character in the actual series), #19's inclusion at this stage may have been seen as redundant.īulma on the other hand proves of immense interest, as not only is she not a playable fighter and an incredibly strange character choice in the first place, but she has more evidence surrounding her former status as a playable character than any of the other characters mentioned above, so much so that her being playable in Budokai 3 was very widely speculated online in the mid 2000s. Gero/Android #20 in Budokai 2, and seeing how their abilities are near-identical (only Dr. TENKAICHI 3 010 EDITOR HEX CODES ANDROIDAndroid #19 in particular was replaced by Dr. However, the fact that announcements exist for these 3 characters imply that if nothing else, the intention to include them was most definitely there, but for whatever reason, they didn't make the cut. Along with those characters, the what-if fusions included in the 2nd game such as Tiencha, Gokule, and the alternate absorptions for Super Buu did not return either, in spite of advertisements claiming that Budokai 3 would feature every character from the first 2 games. He may have been intended to go by that name in the World Tournament mode at some point during development.ĭodoria, Zarbon and Android #19 were all characters who were present in the first Budokai game, but were removed from Budokai 2 and would remain nonentities for the rest of the series. "Shin" was the alias that the Eastern Supreme Kai used when he participated in the 25th World Tournament in the Majin Buu Saga (similarly to how Piccolo uses the title "Majunior"), which is fitting considering that Supreme Kai's announcements are grouped right next to his.
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Based on these “boat as built and modified” factors, a class rating fails to appropriately handicap the boat.Ī boat that is inherently faster than the class rating has an unfair advantage whereas a boat that inherently slower is at a disadvantage. Even with an expert crew the boat cannot be as competitive as a similar boat with an average crew. The net result is that some boats in a class are inherently slower than others. Finally, wear and tear and incidental damage, such as a wet core, may result in a heavier slower boat. While other modifications may add function and convenience at the expense of performance. Some modifications such as, replacing wire/rope halyards with light high tech lines and repowering with modern lighter engines yield a lighter faster boat. Over time any number of other modifications can be made that affect boat performance can be made. If the boat is built with an exceptionally low weight tolerance of +/- 1% two boats coming from the factory could have a 160 lb weight difference, increase that tolerance to 5% and the potential difference increases to 800 pounds. Weight differences can be quite substantial.Ĭonsider a typical 30-foot racer/cruiser with a design weight of 8,000 pounds. Hull weight is a factor in a boat’s speed, heavier hulls accelerate slower than light hulls of the same design and have lower top speeds. It is a fairly common assumption that mass-produced sailboats did not always meet designed weights, especially hand laid fiberglass hulls. Some differences can be attributed to optional equipment selected by the original owner, others to inconsistencies in the building process. While certainly not the intention of the builder or designer, all boats of a class do not leave the boat shed equally built. The resulting rating does provide a fair rating of a class of boats relative to another class of boats however, it is less successful when applied to an individual boat. PHRF attempts to calculate a fair rating for a class of boats by aggregating the results from multiple races sailed by multiple boats driven by multiple crews. And the boat as it was prepared and sailed. How fast a boat sails is dependent upon three broad factors. The implication of the ASP rating is that an optimal boat speed can be predicted based on past performance. The language of PHRF is revealing in its intention, boats are assigned an “Adjusted Speed Potential” based on a base rating and any adjustments due to common modifications such as oversized sails, roller furling, folding/feathering props, and so forth. Of interest here is the most commonly used performance handicapping rule, PHRF. Historically, sailboat handicapping has followed one of three traditions a one design rule, a measurement rule, and a performance handicap. Sailing is perhaps unique in that it handicaps boats and not sailors. Personal performance and course difficulty are considered in golf handicapping. Bowlers are handicapped based on personal performance relative to a league standard. Team sports such as softball are organized in leagues based on skill levels. An investigation into the effects of an Individual Performance Handicapping System on fleet competition at the local level by David Lochner and Richard White¹ at Oswego Yacht Club² in October 2015.įair competition is a central tenant in all athletic competition. It was Brustad who delivered the final score for Eastern, getting her attack to go and winning the third set 25-18. The Eagles would refocus, putting together a 7-2 stretch to give them a 20-15 lead and nearing the game win. The Thunderbirds would not go quietly in the third, firing off a 5-0 run to tie the set at 13. Brustad dropped in two more kills and Bacon added two of her own for a 13-8 lead. Looking for the sweep, Eastern brought the intensity again to open the third set. 375 attack percentage and limited SUU to a. Despite a late push from the Thunderbirds, Eastern went on to win the second set, 25-18, and now had a 2-0 lead in the game. Radke stepped up her attack and Brustad added to her kill total during the run. After being tied at four, the Eagles blitzed SUU with a 13-1 run and held a 17-5 advantage in the set. With the lead, Eastern continued to score effectively in the second set. 312 in the first set, while holding the Thunderbirds to. Alyssa Radke and Renata Lopez Morales put the exclamation mark on the set with a block and the Eagles had a 25-18 win in set one.Įastern led the game 1-0 after hitting. At 16-14, Eastern picked up kills from Katie Fleck and Sage Brustad to build separation on a 4-1 run. The Eagles maintained the lead but, SUU remained close, keeping the score within a few points. #Eagles next game series#A series of errors from the Thunderbirds and a block by Sadie Bacon and Lindsey Russell gave Eastern a 9-5 lead. The game started close, as the Eagles earned kills from multiple players. We've got a lot of work to do, but this team is making some big strides and we are very proud of them."Įastern faced off against former Big Sky member, Southern Utah, in the team's first game of the day. I thought we were very close this evening in each set, but in the end, we ran out of time. "We have been focused on serving and that showed today in both matches. "Today was a good day for the Eags," head coach Jon Haruguchi said. The Eagles swept Southern Utah in the morning and dropped their second game against Butler, 0-3. Eastern Washington volleyball split games on Friday, in the first day of the Boise State Classic. Waters was quick to respond to these allegations, using Rolling Stone as a conduit as well: “That is not true, Thom. In fact, just last year in this publication, the esteemed Rabbi Shmuley Boteach championed American Express for dumping plans to invest $4 million on a tour sponsorship with Waters. Waters himself has seen his own public image demonized on the back of his fervent, spirited advocacy for the people of the West Bank, where his pointed words against Israel have gotten him labeled as anti-Semitic by some critics. Yet in the last year-hell, in the last 150 days-the singer has witnessed a character straight out of “Pigs” insist on building a wall while barking out fleeting thoughts on Twitter via his iPhone, all while the desperate public need to stay “on brand” rolls through the fields of intellectual discourse like a plague of locusts. Through the complex grandiosity of such classic Pink Floyd albums as Wish You Were Here, Animals, The Wall and The Final Cut, Roger Waters the lyricist gave the world a glimpse of existing under the ham-handed fist of corporate zealotry. Hence the question posed in the title of the fifth and finest solo album yet from Waters, which arrives at a time where the nightmares of the artist’s most imaginative material has become an out-of-control beast of American exceptionalism gone awry. And when you compound it with the way both the songwriter and the author who inspired him predicted the likes of television news being repackaged as entertainment, mandatory lifestyle branding and a “Made from TV” presidential candidate in the age of Donald Trump is pure prophecy in motion. The addiction to smartphones, iPads, Kindles, Nooks, PSPs, laptops, FitBits, Apple Watches and whatnot surely has surpassed the expectations of both Waters and Postman in terms of screen addiction. Yet when you skip ahead a quarter century, where the former Pink Floyd frontman would finally follow up his 1992 opus with an LP entitled Is This the Life We Really Want?, there’s a screen in just about every human hand in modern society. And one with access to the embryonic World Wide Web via Prodigy was even rarer. When Roger Waters released Amused to Death-an album based on the Neil Postman book about the addiction to television screens-the computer was still an uncommon part of a domestic household.
John Motson was the first commentator for the FIFA series, and has worked alongside Ally McCoist, Andy Gray, Des Lynam, Mark Lawrenson and Chris Waddle. Months later, World Cup 98 was EA's first officially licensed tournament game. This version featured much improved graphics, a complete World Cup with qualifying rounds (including all national teams) and refined gameplay. FIFA 97 improved on this with polygonal models for players and added an indoor soccer mode, but an early pinnacle was reached with FIFA: Road to World Cup 98. For the first time with real player names by obtaining the FIFPro license, the PlayStation, PC, 32X and Sega Saturn versions used EA's "Virtual Stadium" engine, with 2D sprite players moving around a real-time 3D stadium. While FIFA 95 did not add much other than the ability to play with club teams, FIFA 96 pushed the boundaries.
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