Keys to good documentation

Keys to Good Documentation

By Rory Prue

Strategies

Documentation Is A Professional Skill

• 28 % of run time spent on reports• As important as other skills• Can make you look professional or

unprofessional -- you decide

Strategies

Make Time for Documentation• Patient still #1 Priority• Document as soon as possible• Cheat sheets are good tool• Use a method that works for you

Strategies

Plan Before Starting to Write• Decide what to write• Use a system and stick with it

• S. O. A. P.• C.H.A.R.T.• N.A.P

S.O.A.P.

S ubjective• What the patient, family, bystanders

SAY• Use patient’s own word• Use quotes when quoting anyone• Part of your patient assessment

S.O.A.P.

O bjective• What you OBSERVE or SEE• Includes vitals not documented

elsewhere• Part of patient assessment

S.O.A.P.

A ssessment• Your assessment of previous findings• NOT PATIENT ASSESSMENT!• Often same as Chief complaint• e.g. syncopal episode or

hypoglycemia• Should only be a few words

S.O.A.P.

P lan of Action• What you do for your patient• All treatment should go here• Try not to repeat what may be

documented elsewhere

Strategies

Remember Your Audience• Billing (non-medical people)• QI• Lawyers• Insurance investigators• Etc.

Strategies

Strive for a Meticulous Report• Legible handwriting• Proper spelling• Use only approved medical

abbreviations

Strategies

Documentation a memory tool• You may go to court years after the

fact• Medicare may ask for more

information months after the call

Strategies

Create a Detailed Picture• Describe the scene & events• Explain the patient’s condition• Give past medical history• Detail your findings• Document all treatment rendered

REMEMBER: IF IT IS NOT DOCUMENTED, YOU DID NOT DO IT!

Strategies

Create a Detailed Picture (cont.)• Report any changes in patient’s

condition• Explain any extenuating

circumstances (extrication time)• Note events that occurred en route• Note any changes in patient’s status

Strategies

Detail your actions & patient’s condition• Document times

• Not only dispatch times• Times of treatment• Changes in patient’s status• Special events

• e.g. time down, time without oxygen, extrication times, etc.

Strategies

Involve other Personnel• All crew members responsible• One person should do writing• Discuss the run and what happened• Make sure everyone agrees

Strategies

Proofread Your Documentation• Ensure its accuracy• Look for mistakes• Ask other crew members to read• Read it aloud

Strategies

Correct errors in a proper manner• Remember it is a legal document• Do not erase or obliterate• Use one line through

• Write error• Initial it• Date it

Strategies

Understand Protocols• Refusals #1 EMS Lawsuits

• 50% to 90% of all Lawsuits• Accurate documentation Crucial

• Non-billable runs are also important for your protection• False calls• Mutual Aid• Canceled Calls

Strategies

Review Past Reports• Helps you to improve• Helps you to be consistent• Learn from your mistakes & others• Learn from others

Cultivate Good Skills

Realize Documentation is a Skill just like starting an IV

Develop good writing skills Use small pocket spellers Find someone that has good

documentation skills Accept Constructive Criticism

Conclusion

Documentation Reflects Our Professionalism

• People do not see you in action, but they read your reports

• You are only as good as your documentation