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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