You can paint a good clinical picture without duplicating your charting. Unfortunately charting has become more and more about how to get reimbursement rather than a good medico-legal record of the patient encounter. I can't tell you how much fluff is in every report that companies fax to us. We also get quite a few transports in where there were real practice issues that we need to address with medical directors, and the charting they send is completely useless and neither reflects the patients care as they gave in report nor the real reason the patient was being transported anyway. Our EMS phones are recorded and we save the recordings both for QC and legal defense, and its shocking how many EMS phone reports aren't even close to what they chart in their records.I disagree with almost everything written above. As someone who deals with documentation compliance on the regular, here’s a couple of basics that you can pass on to your crews. ... As far as duplication of info, Steve Wirth said it best, “if your providers are worried about making mistakes in double documentation, they are working in the wrong field”.
As mentioned above, a clinical picture should be painted AND ea company will have its own standards. I’m using a template that I’ve developed years ago, and it never fails. It lists, in chronological order, the clinical findings starting with arrival on scene, paints a brief picture of the events leading to 911 activation, primary assessment + pertinent (+)/(-)’s, interventions, transport decision, reassessment en route + any clinically important changes, and ToC at destination. Some info is repeated for redundancy’s sake.What info goes where? What info should be repeated if any? please lay this out for me
That isn't documentation by exception. You only chart abnormal things. So you would not chart strong radial pulses. You would only chart the abnormal and assume everything is normal if otherwise undocumented.
A BGS is an objective finding which is obviously pertinent to the assessment of someone with neuro changes. It would go in the objective part of the chart with the VS, EKG interpretation, IV location/size, IVF choice and rate, etc. If it is normal and doesn't require treatment, there's no reason to mention it anywhere else in the documentation.
The duplication thing has been hit on at every finance education session I've attended over the last few years and the general trend that we have experienced is to justify treatments in the narrative but not necessarily add in doses or anything like that. As for documenting assessments, ESO has an entire assessment page. We are forbidden to document anything in the narrative regarding objective assessment and instead use that page. It has a multitude of drop downs as well space for notes for each system. This allows you to ensure you are not contradicting the boxes you have checked.I disagree with almost everything written above. As someone who deals with documentation compliance on the regular, here’s a couple of basics that you can pass on to your crews.
All of the info that is listed in a drop down, check box or entered in the flowchart is there as a trigger. It’s either there to trip a QM flag, accountability, NEMSIS tracking item or as a reminder to add it to the narrative. The narrative is the important part.
It’s vital to paint a good clinical picture of each encounter in the narrative. Do not let your providers get away from documenting details by saying, “treatment per protocol” or “see flowchart”. The narrative should be a complete accounting of the entire patient contact. Lack of narrative is FAR more difficult to defend than a solid descriptive narrative.
As far as duplication of info, Steve Wirth said it best, “if your providers are worried about making mistakes in double documentation, they are working in the wrong field”.
BGL should be checked, along with every other vital sign, and documented as such. Failing to document it would be on par with failing to do a stroke screen on a stroke patient; your defense of "well, it was normal, but not written down" probably wouldn't go over well, however on this stroke patient, did you check for pedal edema? did you check for oral trauma? did you check for rectal hemorrhaging? did you document all these checks? likely not, because it's unrelated to the patient's complaint, so we assume it's normal unless documented otherwise.
For clarification, do the billing experts want you to duplicate document everyone, or only put it in one area to prevent contradictions?The duplication thing has been hit on at every finance education session I've attended over the last few years and the general trend that we have experienced is to justify treatments in the narrative but not necessarily add in doses or anything like that.
We were told to make sure treatments were included in the narrative as well as justification and response to them. However they stopped short of adding specific doses in the narrative. Billing people are much less concerned about documenting assessments it would seem. For me though, I am going to use the Assessment tab in ESO to document that, it is more thorough (for me) than typing it out and the generated report gives a whole page on the assessment if you use it that way.For clarification, do the billing experts want you to duplicate document everyone, or only put it in one area to prevent contradictions?
No one here has said this. Sorry you don't like the fact that others disagree with you, but that doesn't mean their motivations for thinking differently should be chalked up to laziness.I think everyone needs to get out if the mindset of "I like to do it this way" and "it's better for me if I use this tab".
Fair enough. Just keep in mind that your lawyers and billing consultants probably have zero interest in the efficiency of your charting.We retain legal counsel and a consultant to advise us of best practices from a reimbursement and legal standpoint. Those are the standards we follow.