Documentation Policy

EpiEMS

Forum Deputy Chief
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Does your service have a written documentation policy? If so, are any key items it's missing that you'd like added?
 

NysEms2117

ex-Parole officer/EMT
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Does your service have a written documentation policy? If so, are any key items it's missing that you'd like added?
like IA? IR? or everyday normal documentations?
 

VentMonkey

Family Guy
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Our county has a list of "acceptable medical abbreviations" that we can use, and otherwise requires our PCR's to be "plain text", but other than that, not really.

We are going to switch over to a new software program by the beginning of next year, and are about to start training classes on it within the next few weeks as well (yaaay NEMSIS).

As far as our service, multiple things can count as infractions, sometimes after the fact, so it's hard to say what can, or can't be/ should, or shouldn't be tailored as hindsight is often 20/20.
 

Handsome Robb

Youngin'
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Our documentation standards are like 20 pages long.

Trust me, they didn't miss anything.


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LanceCorpsman

Forum Lieutenant
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Our only policy is to make sure the call is billable. We have a set of policies that we "must" do and document.
One example is that patients cannot "walk to the ambulance." Even if they are completely ambulatory/healthy, it is our policy so we can get paid.
Another one is O2 administration, our system and billing dept requires us to give O2 to every patient to ensure billing. My EMS supervisor says "Every chest pain and stroke gets high flow O2, even if they are at 98% SpO2." The reasoning behind it is for billing purposes.
 

NomadicMedic

I know a guy who knows a guy.
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Our only policy is to make sure the call is billable. We have a set of policies that we "must" do and document.
One example is that patients cannot "walk to the ambulance." Even if they are completely ambulatory/healthy, it is our policy so we can get paid.
Another one is O2 administration, our system and billing dept requires us to give O2 to every patient to ensure billing. My EMS supervisor says "Every chest pain and stroke gets high flow O2, even if they are at 98% SpO2." The reasoning behind it is for billing purposes.

Fraud much?
 

PotatoMedic

Has no idea what I'm doing.
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...
Another one is O2 administration, our system and billing dept requires us to give O2 to every patient to ensure billing. My EMS supervisor says "Every chest pain and stroke gets high flow O2, even if they are at 98% SpO2." The reasoning behind it is for billing purposes.

I've never heard of a company mandating medical treatment regardless of pt condition. Does not sound legal. Personally I would ignore it and if given crap take it to the county.
 

SpecialK

Forum Captain
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Every patient must have a patient report form completed. This includes on patients whom assessment is only brief and verbal.

The only exception is when multiple patients are assessed at the scene of a road crash. All patients can be grouped into one PRF

Not completing a PRF is a serious and significant departure from the professional standards of an Ambulance Officer, and the patient's Health and Disability Consume Rights, and is grounds for a formal warning if the policy was clearly not followed. It is taken extremely seriously and I don't not agree with it.

There are a list of accepted abbreviations yes.

Most documentation I had read is poor, and documentation of patients who are not transported is equally poor. It's not that the English language ability of ambulance personnel is poor, it is not including the relevant information. If it is not written down, it did not happen. Historically I do not think ambulance personnel who were vocationally educated received very good training on documentation and how important it is. The move to a mandatory degree has helped because it requires a much greater level of knowledge.

For example many personnel do not record all vital signs on the PRF (the most commonly missed is respiratory rate), or they do not write a detailed enough history or exam, probably because it wasn't performed, but again, if it's not written down, the assumption is it did not happen so it very may well of. Patients who are not transported need to have a detailed enough PRF written to show personnel have reasonably excluded everything which would require immediate transport, and they also need to have the treatment and referral plan developed by ambulance personnel documented. A common example might be they made a referral for the patient but did not document to whom it was made or who they spoke with. Another common one is using the "red flags" section of the CPGs and just writing "no red flags" or "no orange flags" without specifically writing them out and putting "no" next to them.

My documentation is not superb, I have missed things and been given the stern word for it. I have seen some great PRFs, but most are passable and some of them have been horrendous. At least with the move to ePRF nobody can blame bad handwriting!
 

LanceCorpsman

Forum Lieutenant
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Fraud much?

That is exactly what I said. Guess who is hated by the supervisor and the billing dept the most?

I've never heard of a company mandating medical treatment regardless of pt condition. Does not sound legal. Personally I would ignore it and if given crap take it to the county.

I do ignore it. It sucks because all of the fresh EMTs that come out of my supervisors class likes to put O2 on everything, regardless of respiratory status. I do my best to teach them and actually advise them of the ECC and other guidelines. In the class, it is taught that trauma, chest pain or stroke = High flow O2.

I do partially blame the poorly written standing orders in our county that allows this to happen. But yet again, its all about the people interpreting the standing orders.
 
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EpiEMS

EpiEMS

Forum Deputy Chief
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like IA? IR? or everyday normal documentations?

Looking more for everyday normal documentation, like "How do I document the chief complain of the COPD'er who called 911 for an exacerbation?" Because officially, I have no guidance - unofficially, I get mixed guidance like "Give a quote" or "summarize the complaint". In my mind, either is acceptable, but there's no official reference for me.

As far as our service, multiple things can count as infractions, sometimes after the fact, so it's hard to say what can, or can't be/ should, or shouldn't be tailored as hindsight is often 20/20.

I have the same issue! I would just like a concise document, and I want to propose one.

Our documentation standards are like 20 pages long.

Trust me, they didn't miss anything.

Sent from my iPhone using Tapatalk

Any chance you could send a version to me? Would love to read through a comprehensive one.

Our only policy is to make sure the call is billable. We have a set of policies that we "must" do and document.
One example is that patients cannot "walk to the ambulance." Even if they are completely ambulatory/healthy, it is our policy so we can get paid.
Another one is O2 administration, our system and billing dept requires us to give O2 to every patient to ensure billing. My EMS supervisor says "Every chest pain and stroke gets high flow O2, even if they are at 98% SpO2." The reasoning behind it is for billing purposes.

Seems a bit unethical, at the least, as you said. Oof...

The move to a mandatory degree has helped because it requires a much greater level of knowledge.

This definitely would help! I find that my college-educated peers write better documentation...especially the one or two who are lawyers...
 

NysEms2117

ex-Parole officer/EMT
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Looking more for everyday normal documentation, like "How do I document the chief complain of the COPD'er who called 911 for an exacerbation?" Because officially, I have no guidance - unofficially, I get mixed guidance like "Give a quote" or "summarize the complaint". In my mind, either is acceptable, but there's no official reference for me.
we get boxes, however i was told very early on that if you document everything you did, and you are not completely clueless in your job(going out of scope ect) you essentially cannot lose in court/ company. I usually don't end up filling them out because im a basic on an ALS rig(CCT more specifically) however, when i do i fill out the boxes ect, then go and summarize anything that happened in my personal documentation at the bottom. I also take no chances ESPECIALLY on RMA's. i also put a little personal narrative at the bottom of my RMA's.
 
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OP
EpiEMS

EpiEMS

Forum Deputy Chief
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we get boxes, however i was told very early on that if you document everything you did, and you are not completely clueless in your job(going out of scope ect) you essentially cannot lose in court/ company. I usually don't end up filling them out because im a basic on an ALS rig(CCT more specifically) however, when i do i fill out the boxes ect, then go and summarize anything that happened in my personal documentation at the bottom. I also take no chances ESPECIALLY on RMA's. i also put a little personal narrative at the bottom of my RMA's.

We use EMSCharts, so I am OK with the boxes, I just find that I get conflicting directions depending on who is reviewing the chart. I feel pretty good about the soundness of my charting, but I am pretty comprehensive (I think).

RMAs are definitely harder to document - I actually would like more guidance on how to document one from, say, an attorney. I find that I focus on making sure I offer transport multiple times and that they understand the consequence of the refusal (obviously, I also document said conversation).
 

SpecialK

Forum Captain
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For non-transports here is what I think is a good idea:

Write why you did not recommend transport and the substance of what you discussed with the patient including whatever advice you gave them about what to do if they get worse. You need to show enough information that somebody who was not present can pick up your PRF and see what you did and why. Often what the PRF says, and what the crew says, will differ; and the general feeling from what I've seen is to err-on-the-side-of-the-PRF.

If you recommend referral to somewhere other than ED, document to where, in what time-frame, and if possible speak with whomever yourself to physically make the referral and tell them what to expect then write down the name and position of the person you spoke with.

If I referred somebody with a known mental health problem to the community mental health nurses and they accepted to see the patient I would write something like :

"Discused with John and his mum: Not recommending attendance at ED as no physical injuries or illness that require it. While John has expressed thoughts of suicide he is not actively wanting to kill himself or hurt himself or somebody else so doesn't require referral to crisis team. He and mum said he is well known to mental health outreach nurses. Spoke to them (RN Susie) who agreed they will see him at home in approximately two hours. Mum is with John and will remain with him. She has a working phone. Advised her to call us back if John gets worse between now and when mental health team arrive. Pt and mum happy with plan."

A common inadequacy seen on PRFs is something like "discussed options". While discussing options is good, it needs to be specific, which options did you discuss? Which did you firmly recommend? What did the patient say to each of them?

If a competent patient is refusing a firm recommendation then the above is good, but write down what you discussed with the patient about why you were recommending whatever they declined, what they said in response, and what you said to do if they get worse. ePRF can record audio which is great for these sorts of things.
 
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EpiEMS

EpiEMS

Forum Deputy Chief
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For non-transports here is what I think is a good idea:

That's a really good point - I definitely don't do a good enough job of documenting options. That being said, our options are to encourage transport or to encourage transport but suggest that it is not necessary. My system is pretty awful about that. I would like explicit instructions to be able to tell people "you don't need to go to the ED" (for truly low risk conditions - I have a low threshold for risk to the patient).
 
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