I have a question about documentation. If you don’t do a full head to toe on a patient, which you rarely do, how do you document it? I’ve seen some people put not assessed on most everything except the obvious stuff, and I’ve also seen people put no abnormalities on everything. I mean I can see putting not assessed on pelvis/GU if you don’t do anything, but what about arms for example? If they’re wearing short sleeves you can see them, but if you don’t touch them what do you put? If they’re wearing short sleeves but long pants do you put no abnormalities for arms, but not assessed for legs? What about if you press on their abdomen but don’t look at it? Not assessed or no abnormalities? That’s what confuses me.
Documentation question
- Thread starter bdoss2006
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CCCSD
Forum Deputy Chief
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How many times are you going to ask this question? Again… you really are lacking in the basics. Ask your employer for lots of field training.
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Are you expected to do a full trauma assessment on every patient?
As part of my medical evaluation I’d ask the patient how if they had pain in a number of areas and our service had us document head pain, neck pain, chest pain, stomach pain extremity pain, and nausea. That was it.
For a trauma patient I would do a full trauma assessment per our protocol, which aligned with the NREMT trauma assessment. It didn’t take long.
As part of my medical evaluation I’d ask the patient how if they had pain in a number of areas and our service had us document head pain, neck pain, chest pain, stomach pain extremity pain, and nausea. That was it.
For a trauma patient I would do a full trauma assessment per our protocol, which aligned with the NREMT trauma assessment. It didn’t take long.
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This is exactly what should have been covered by your initial training. You don't do a full head to toe on EVERY patient. If I'm REQUIRED to put SOMETHING in EVERY field for a head to toe, then I might choose an "other" option and enter "deferred" in that field for those areas that I chose not to examine.
I'll give you a hint about this... for ALL patients, including trauma patients, I'll ask an open question about what's bothering them the most. Then I'll drill down from there with my assessment questions. Stuff that's also obviously NOT a problem, I might write there there are no other obvious signs of trauma or illness in that area. If something is obviously "normal" then I might write or check "within normal limits." Just make sure it's not a "we never looked" exam when you do that.
I'll give you a hint about this... for ALL patients, including trauma patients, I'll ask an open question about what's bothering them the most. Then I'll drill down from there with my assessment questions. Stuff that's also obviously NOT a problem, I might write there there are no other obvious signs of trauma or illness in that area. If something is obviously "normal" then I might write or check "within normal limits." Just make sure it's not a "we never looked" exam when you do that.
Here we go again. I had hoped you’d just left the forum… actually this is only the second time, and no one really answered it the first time, and no, I am not “lacking in the basics”. Nor do I need “lots of field training”. I have 4 jobs, and all have signed me off to run solo without any issues. I have received multiple compliments about my skills from multiple people. You are just plain wrong.
Dude seriously you need to lay off attacking everyone who isn’t spoon feeding you the answers you want. This is real basic stuff. Your employer should be telling you how they need things documented. Billing is a real thing and they will know best for how it needs to be done and can guide you through it.
CCCSD
Forum Deputy Chief
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Your posting history tells a different story. You are clearly not trained, educated, nor safe in your required BASIC skills. Again, read your own posts. Just because some elderly person you transported on an IFT thanks you, doesn't mean you know what you are doing.
If you are working “four jobs”, you have other issues. The main one being lack of training, as you’ve stated you have been “signed off”, yet you keep asking on the internet instead of YOUR EMPLOYER.
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Looks like I'm going to be watching this thread closely.
DrParasite
The fire extinguisher is not just for show
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Whatever you do, please stop checking rectal tone on every patient over the age of 50... pretty sure it's not related to their wrist injury....
All kidding aside, this is a basic question. document what you do. if you didn't do a head to toe exam, don't document that you did. If someone has an isolated injury, perform a focused exam. I hate this phrase, but if you don't document it, you didn't do it (and as such, you shouldn't be documenting that you confirmed the patient's rectal tone was normal, because you shouldn't be checking it).
If I have a patient, I might put +CMS in extx4, which means I checked the circulation, motor and sensation in all 4 extremities. however, that doesn't mean I examined their thigh for anything abnormal. I might not look at a patient's abdomen (which is why I won't document that I did), but I might say ABD = SNT (abdomen is soft and not tender). document what you do, don't falsify your documentation and say you are doing something that you aren't.
All kidding aside, this is a basic question. document what you do. if you didn't do a head to toe exam, don't document that you did. If someone has an isolated injury, perform a focused exam. I hate this phrase, but if you don't document it, you didn't do it (and as such, you shouldn't be documenting that you confirmed the patient's rectal tone was normal, because you shouldn't be checking it).
If I have a patient, I might put +CMS in extx4, which means I checked the circulation, motor and sensation in all 4 extremities. however, that doesn't mean I examined their thigh for anything abnormal. I might not look at a patient's abdomen (which is why I won't document that I did), but I might say ABD = SNT (abdomen is soft and not tender). document what you do, don't falsify your documentation and say you are doing something that you aren't.
DrParasite
The fire extinguisher is not just for show
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No, they won't... they will tell you what needs to be done to get the bill paid. however that isn't "how it needs to be done," as writing a chart for billing and writing a chart that will stand up to clinical or legal scrutiny has different levels of "how it needs to be done." the PCR has many more audiences besides billing.
Here is some reading material on this exact topic:
Top 10 Documentation Mistakes Ambulance Providers Make — and Supervisors Overlook - JEMS: EMS, Emergency Medical Services - Training, Paramedic, EMT News
A detailed summary of a dynamic presentation on improving documentation given by Steve Wirth, Esq., EMT-P, at the annual meeting of the American Ambulance Assocation (AAA) on Saturday, Sept. 8, 2018, at the MGM Grand Hotel Conference Center in Las Vegas.
www.jems.com
EMS Lawline: Three Documentation Best Practices to Reduce Risk and Lower the Patient's Financial Vulnerability - JEMS: EMS, Emergency Medical Services - Training, Paramedic, EMT News
The bottom line is that accurate, complete and timely completion of PCRs is a legal and ethical responsibility of the EMS practitioner, writes Steve Wirth.
www.jems.com
3 steps to properly documenting patient care in EMS
All members of the EMS team must commit to improving patient care documentation by expanding on the details and ensuring completion
www.ems1.com
EMS Documentation: Ensuring Accurate and Comprehensive Records of Patient Care - DoveMed
Discover the importance of comprehensive EMS documentation and its impact on patient care and quality improvement. Explore key elements of effective documentation, challenges faced, and strategies to enhance the quality and accuracy of EMS documentation.
www.dovemed.com
Documentation & Patient Care Reporting News - JEMS: EMS, Emergency Medical Services - Training, Paramedic, EMT News
Get the best news on Documentation & Patient Care Reporting from the Journal of Emergency Medical Services.
www.jems.com
I would encourage you to attend an EMS documentation class from an EMS attorney (yes, I said attorney, someone who went to law school, not a provider who has been around for a few years)... ask questions from someone who has been in court over EMS documentation. there is a lot of urban legends and old wives tales about documentation that come from EMS providers passing down one bad suggestion to the next requirement. and @bdoss2006, I do encourage you to do your own research on these topics; while CCCSD might be crankier than most, he's not wrong, and if will make you a better provider if you read the opinions of other experts, and come to your own conclusion as to what the best option will be, based on your own education.
I hear you but was just giving him a starting point and hoping he’d finally start asking someone he actually works for these important questions. Figured if he’d talk with a billing person and then didn’t get a complete answer there, he’d finally ask a supervisor and get more information on how to actually do it. I’ve been lucky over the years and back when I first started paramedic school and in a couple refreshers had David Givot give lectures and walk through what is important on writing a run report. Was beneficial that he could talk about it from the legal side and also the provider side.No, they won't... they will tell you what needs to be done to get the bill paid. however that isn't "how it needs to be done," as writing a chart for billing and writing a chart that will stand up to clinical or legal scrutiny has different levels of "how it needs to be done." the PCR has many more audiences besides billing.
Here is some reading material on this exact topic:
Top 10 Documentation Mistakes Ambulance Providers Make — and Supervisors Overlook - JEMS: EMS, Emergency Medical Services - Training, Paramedic, EMT News
A detailed summary of a dynamic presentation on improving documentation given by Steve Wirth, Esq., EMT-P, at the annual meeting of the American Ambulance Assocation (AAA) on Saturday, Sept. 8, 2018, at the MGM Grand Hotel Conference Center in Las Vegas.
EMS Lawline: Three Documentation Best Practices to Reduce Risk and Lower the Patient's Financial Vulnerability - JEMS: EMS, Emergency Medical Services - Training, Paramedic, EMT News
The bottom line is that accurate, complete and timely completion of PCRs is a legal and ethical responsibility of the EMS practitioner, writes Steve Wirth.
3 steps to properly documenting patient care in EMS
All members of the EMS team must commit to improving patient care documentation by expanding on the details and ensuring completion
EMS Documentation: Ensuring Accurate and Comprehensive Records of Patient Care - DoveMed
Discover the importance of comprehensive EMS documentation and its impact on patient care and quality improvement. Explore key elements of effective documentation, challenges faced, and strategies to enhance the quality and accuracy of EMS documentation.
Documentation & Patient Care Reporting News - JEMS: EMS, Emergency Medical Services - Training, Paramedic, EMT News
Get the best news on Documentation & Patient Care Reporting from the Journal of Emergency Medical Services.
I would encourage you to attend an EMS documentation class from an EMS attorney (yes, I said attorney, someone who went to law school, not a provider who has been around for a few years)... ask questions from someone who has been in court over EMS documentation. there is a lot of urban legends and old wives tales about documentation that come from EMS providers passing down one bad suggestion to the next requirement. and @bdoss2006, I do encourage you to do your own research on these topics; while CCCSD might be crankier than most, he's not wrong, and if will make you a better provider if you read the opinions of other experts, and come to your own conclusion as to what the best option will be, based on your own education.