Having an issue with Documentation and Charting

garg. Yea. Nursing school... almost over...
 
Im told that AMS is not possiable as a chief complaint. Because the PT cant tell me that if they are altered.

I am told that if the PT is in Resp Distress, but cant voice that, Then the CC is None Voiced.

If the PT is seizing, guess what. No Complaint voiced. ...

When I Q&A these charts, and I see said CC's, Then I have to flag them, and tell them that its not a chief complaint.

i feel as if my head is going to explode.
 
Tell you employer what the bartender said once on "Murphy Brown":

"Christ, Frank, what do want from me?! I know, treat me like any other cheap w&^re, write what you want me to say on a twenty dollar bill!!!".
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(Paraphrase, it was funnier in 1988)
 
I'm confused what the issue is. What is the problem with putting "none voiced"?
 
Are the crews putting their working diagnoses for chief complaint, or what?
 
When we began using EMSCharts and sent our people to be trained by EMSCharts they explained that the CC field is "why are we here". So simple one worded answers like, seizures, or AMS, ect, unresponsive. Unfortunately the training EMSCharts offers online is vague, simply saying that field is for the chief complaint. I assumes it is because they dont think they have to explain what a CC is to medical personnel

When they say it is wrong, based on whos opinion? I would fill it out the way i felt accurately documented the call. What does your medical director say? i assume he is your S3
 
Where I work we put what the pt tells us or why we were called....SOB, Arrest, not feeling well, seizure etc.

I really don't see why this is such a big deal. It does not affect the pt, billing and there is a section for a narrative where you can write as much as you want. Is that not good enough?

I wish the biggest issue where I work now was as trivial as this.
 
Medic Tim said:
Where I work we put what the pt tells us or why we were called....SOB, Arrest, not feeling well, seizure etc.

I really don't see why this is such a big deal. It does not affect the pt, billing and there is a section for a narrative where you can write as much as you want. Is that not good enough?

I wish the biggest issue where I work now was as trivial as this.
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For some strange reason I doubt this is the biggest issue.

Maybe the easiest to fix.
 
Writing style should reflect the position one holds. As Operations Officer I would expect a higher level than demonstrated in that letter. At your level I would expect you to be concise, succinct, and to the point.

Presuming to instruct your chief on the definition of chief complaint is in poor form. I hope you have not sent that letter yet, but as they say, opinions are like... so my opinions are just that.

Good luck with this.
 
Sandog said:
Writing style should reflect the position one holds. As Operations Officer I would expect a higher level than demonstrated in that letter. At your level I would expect you to be concise, succinct, and to the point.

Presuming to instruct your chief on the definition of chief complaint is in poor form. I hope you have not sent that letter yet, but as they say, opinions are like... so my opinions are just that.

Good luck with this.
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Sorry, I just realized I should have said that in a nicer way. I must be having one of those days.
 
Maybe OP has that rare boss who is collaborative and knows how to take it when someone points out there's doodoo on his shoe.
 
well I just asked to speak with him. We looked over the SOPs and what EMS charts says, and found the gaps . we have formed a committee and we will be addressing the charting issues.

Thanks for the info guys!
and the support / slaps in the face! :)
 
Aw, those weren't slaps!

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Good luck with that and school.
 
EchoMikeTango said:
well I just asked to speak with him. We looked over the SOPs and what EMS charts says, and found the gaps . we have formed a committee and we will be addressing the charting issues.

Thanks for the info guys!
and the support / slaps in the face! :)
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I still don't understand what the issue is. Why is it such a problem to write "None voiced"?
 
mycrofft, I know dude! Ive been here long enough to know when people are serious!

and the deal is mainly, that I have, if there is an obvious complaint / issue / reason why we were called, then Nothing Voiced seems stupid to put in that box.

but I dont feel like getting back into it tonight. I am ready have 2 headaches from this , and im ready for bed!
 
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