EpiEMS
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Does your service have a written documentation policy? If so, are any key items it's missing that you'd like added?
like IA? IR? or everyday normal documentations?Does your service have a written documentation policy? If so, are any key items it's missing that you'd like added?
Our only policy is to make sure the call is billable. We have a set of policies that we "must" do and document.
One example is that patients cannot "walk to the ambulance." Even if they are completely ambulatory/healthy, it is our policy so we can get paid.
Another one is O2 administration, our system and billing dept requires us to give O2 to every patient to ensure billing. My EMS supervisor says "Every chest pain and stroke gets high flow O2, even if they are at 98% SpO2." The reasoning behind it is for billing purposes.
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Another one is O2 administration, our system and billing dept requires us to give O2 to every patient to ensure billing. My EMS supervisor says "Every chest pain and stroke gets high flow O2, even if they are at 98% SpO2." The reasoning behind it is for billing purposes.
Fraud much?
I've never heard of a company mandating medical treatment regardless of pt condition. Does not sound legal. Personally I would ignore it and if given crap take it to the county.
like IA? IR? or everyday normal documentations?
As far as our service, multiple things can count as infractions, sometimes after the fact, so it's hard to say what can, or can't be/ should, or shouldn't be tailored as hindsight is often 20/20.
Our documentation standards are like 20 pages long.
Trust me, they didn't miss anything.
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Our only policy is to make sure the call is billable. We have a set of policies that we "must" do and document.
One example is that patients cannot "walk to the ambulance." Even if they are completely ambulatory/healthy, it is our policy so we can get paid.
Another one is O2 administration, our system and billing dept requires us to give O2 to every patient to ensure billing. My EMS supervisor says "Every chest pain and stroke gets high flow O2, even if they are at 98% SpO2." The reasoning behind it is for billing purposes.
The move to a mandatory degree has helped because it requires a much greater level of knowledge.
we get boxes, however i was told very early on that if you document everything you did, and you are not completely clueless in your job(going out of scope ect) you essentially cannot lose in court/ company. I usually don't end up filling them out because im a basic on an ALS rig(CCT more specifically) however, when i do i fill out the boxes ect, then go and summarize anything that happened in my personal documentation at the bottom. I also take no chances ESPECIALLY on RMA's. i also put a little personal narrative at the bottom of my RMA's.Looking more for everyday normal documentation, like "How do I document the chief complain of the COPD'er who called 911 for an exacerbation?" Because officially, I have no guidance - unofficially, I get mixed guidance like "Give a quote" or "summarize the complaint". In my mind, either is acceptable, but there's no official reference for me.
we get boxes, however i was told very early on that if you document everything you did, and you are not completely clueless in your job(going out of scope ect) you essentially cannot lose in court/ company. I usually don't end up filling them out because im a basic on an ALS rig(CCT more specifically) however, when i do i fill out the boxes ect, then go and summarize anything that happened in my personal documentation at the bottom. I also take no chances ESPECIALLY on RMA's. i also put a little personal narrative at the bottom of my RMA's.
For non-transports here is what I think is a good idea: