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Keys to Good Documentation By Rory Prue

Keys to good documentation

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Page 1: Keys to good documentation

Keys to Good Documentation

By Rory Prue

Page 2: Keys to good documentation

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

Page 3: Keys to good documentation

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

Page 4: Keys to good documentation

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

Page 5: Keys to good documentation

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

Page 6: Keys to good documentation

S.O.A.P.

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

elsewhere• Part of patient assessment

Page 7: Keys to good documentation

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

Page 8: Keys to good documentation

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

Page 9: Keys to good documentation

Strategies

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

Page 10: Keys to good documentation

Strategies

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

abbreviations

Page 11: Keys to good documentation

Strategies

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

fact• Medicare may ask for more

information months after the call

Page 12: Keys to good documentation

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!

Page 13: Keys to good documentation

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

Page 14: Keys to good documentation

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.

Page 15: Keys to good documentation

Strategies

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

Page 16: Keys to good documentation

Strategies

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

Page 17: Keys to good documentation

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

Page 18: Keys to good documentation

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

Page 19: Keys to good documentation

Strategies

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

Page 20: Keys to good documentation

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

Page 21: Keys to good documentation

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