Documentation question

bdoss2006

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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.
 

CCCSD

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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.
 

MMiz

I put the M in EMTLife
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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.
 

Akulahawk

EMT-P/ED RN
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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.
 
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bdoss2006

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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.
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.
 

luke_31

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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

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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.
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.
 

ffemt8978

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Looks like I'm going to be watching this thread closely.
 

DrParasite

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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.
 

DrParasite

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Billing is a real thing and they will know best for how it needs to be done and can guide you through it.
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:







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.
 

luke_31

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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:







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.
 
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bdoss2006

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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.
I am “trained, educated, and safe in my required BASIC skills”. A few posts on a forum does not in any way tell you my knowledge or ability. Working four jobs doesn’t mean I have “Other issues”, nor do I lack training. I didn’t mean compliments from patients, I meant from providers that have done this for many, many years. You are totally wrong about me. I am not as dumb as you think.
 

CCCSD

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I am “trained, educated, and safe in my required BASIC skills”. A few posts on a forum does not in any way tell you my knowledge or ability. Working four jobs doesn’t mean I have “Other issues”, nor do I lack training. I didn’t mean compliments from patients, I meant from providers that have done this for many, many years. You are totally wrong about me. I am not as dumb as you think.
Your posting questions that are so basic tells the story, whatever you try and imply.
 

DrParasite

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Before this thread gets locked due to stupidity, please allow me to say 2 things:
@CCCSD, leave the kid alone. At least he's willing to ask questions about what he's unclear on, instead of pretending he knows everything and never asking questions. Maybe he doesn't work for an agency that has a strong training program, or whatever. don't know, don't care. your point has been made.

@bdoss2006, the cranky forum poster isn't wrong; while I commend you for looking for clarification on several topics, many of your questions are on the basic level. I encourage you to use all available resources, but many of your questions should be directed to our agency's training department first, as they can explain how YOUR employer wants things done. Not that it's (necessarily) the right way, but it's what your boss wants you to do. I don't think you're dumb, but it looks better when you use other resources, and show where there is a conflict. You'll note, that I try to provide you with additional sources, that are more credible than any answer you will get from any poster, with the goal that you will do your research, and come to your conclusions. You have asked some really basic questions, ones that should have been answered either by your agency or in your initial EMS training; I would recommend viewing some published articles on the questions you have, and if you are still unclear, and your agency's training department can't help you, then post a question here, including the sources you have checked and what you disagree with.
 
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bdoss2006

Forum Crew Member
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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.
In ESO, which is what 3 of the services I run with use, under the assessment tab, you can click “not assessed” or “no abnormalities” or a host of abnormalities. You don’t actually type it in. So for example, what would you put under the “head” section if you didn’t really touch them? You can still visually see abnormalities, but if you don’t actually feel there head for any deformities, tenderness etc., then what? “No abnormalities” or “not assessed”?
 

FiremanMike

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In ESO, which is what 3 of the services I run with use, under the assessment tab, you can click “not assessed” or “no abnormalities” or a host of abnormalities. You don’t actually type it in. So for example, what would you put under the “head” section if you didn’t really touch them? You can still visually see abnormalities, but if you don’t actually feel there head for any deformities, tenderness etc., then what? “No abnormalities” or “not assessed”?
For the umpteenth time, you need to ask the policymakers at the services you run with.

Why do I say that? The assessment tab isn't required in every state or at every service. It's not a mandated field in my state and as such, it's not mandated at my department. I would much rather my medics document their assessment in the narrative where they are free from restrictive fields baked into PCR software than muddle through and pick "close enough" buttons in the assessment tab.
 

Akulahawk

EMT-P/ED RN
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I didn’t word that correctly. I meant you don’t see any abnormalities, so you don’t touch them. Then what would you put?
Then you look for an assessment tab that states something along the lines of "normal for patient" or you leave it blank and describe what you see in your narrative and state that this is not abnormal for that patient. I had a patient recently who had a large depression in his head. It was normal for him, but would otherwise be an abnormal finding. I left the "head" tab blank and entered in my narrative that the patient had a large depression in his skull, stated PMHx reason for this, and indicated that this was normal for this patient. If I don't see anything abnormal and there's no complaints, I select "normal" under the "head" tab. This isn't rocket science.
 
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