Documentation question

[ChrisMed1]

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.

Late to reply but did they not cover this during your new hire orientation? I am really new also and when I first started as a ER tech I had a week in a half working with someone to basically show me the ropes between regular job duties and very importantly documentation. Now I actually recently started working on the truck a few months ago and even then we have 3 man crews and my first 2wks the other provider with me in the back was showing me how to do the documentations. Now my advice if you have questions about documentation is don't ask a forum on the Internet because every agency has there own way of charting and specific ways they want it done. I would ask your partners or if you have one at the agency you work for ad a FTO they will be able to help.


Now what little I can say from quickly reading through this at 4am on a night shift is never chart something you didn't do it's both dangerous for the patient and illegal to falsify so don't say no abnormalities on something you didn't check because you don't know. Put not assessed, deferred, n/a, etc.