Honestly that report would not be acceptable anywhere i have ever worked. Once i get to a computer i'll type up a sample of my narrative
umm why not? It's an IFT, of a stable patient. i don't see it as unacceptable, especially the rest of the chart is all check boxes. maybe a little light on content, but better than some other people I have worked with.
to the OP, if you want to check out the "approved" medicare and medicaid abbreviations, check out this site:
http://www.cms.gov/apps/acronyms/listall.asp?Letter=ALL
documentation is a very very very subjective thing. what trainer 1 says is good trainer 2 will say is bad. and what trainer 2 says is good trainer 1 might say is bad. and when you ask trainer 3, he will say they are both wrong, and show you the "correct" way to do it.... despite the fact that trainer 1 and 2 will disagree.
The #1 documentation rule is make it documented enough that if you get called into court, you can defend your action, especially if you have little or no recollection of the call itself. the #2 rule is to have enough documentation for the billing department to have the insurance pay the bill.
For me, I always start my narrative with "u/a, EMS found (patient in this position)." from there I typically go into what the patient told me, as well as pertinent negatives, and then go into my assessment. I then list my interventions, and culminating with "M+T to ER, tot RN in room # w/ report given." I also never repeat anything listed in a check box in my narrative. this includes vital signs and other check box worthy items (lung sounds, mental status, etc), unless there is a very specific reason that warrants duplication of documentation (which almost never happens). every +, -, and = gets circled, as does every 1 letter abbreviation.
and my charts only get kicked back due to poor handwriting, never lack of content. once we went to electronic charting, rarely were my charts were kicked back, unless I accidentally skipped a check box.
As a side note, I never write in my chart the patient was secured with seatbelts. never have, never will. every patient is secured with seatbelts, and only if they are not will that be noted in the documentation. similarly, i don't document that the cot was secured in the ambulance, or that a blanket was given if requested, and I never write how many pairs of gloves I used (although this one probably causes the billing people headaches). Certain things I do on EVERY call, and are common knowledge (sort of like where the mess hall is when you are in the marines). Not only that, but just because I write it, doesn't make it accurate; the facility can just say I lied on the chart, and, in the case of the railings, they were never put up, despite what I put on the chart.
