EASTERN AREA PREHOSPITAL SERVICES QA / CQI DOCUMENTATION TRAINING

INTRODUCTION EAPS Documentation Standards State / Command Documentation Trip Log vs Trip Sheet What to include What not to include

INTRODUCTION Why we document Good Documentation Practices Legal Aspect of Documentation Examples Closing and Questions

EAPS has specific documentation standards. Many that are very different than other EMS agencies. Our billing and admin staff try to be on top of all new insurance requirements and we adapt our documentation accordingly.

Page 1 - Dispatch Page one is pretty self explanatory. Make sure your crew assignments are correct and you have listed the correct shift. Anyone shown in the activity log preforming a procedure must be listed as crew.

Patient Information Get as much demographic information as you can. EAPS requires an estimated weight for all patient contacts. Signatures are required for all patient contacts. If you get a refusal the consent/privacy form should also be signed.

Patient Information Make every effort to secure billing information on every transport and patients that receive treatments. Even refusals that receive treatment of any type. If you can get this now, we will have it for future calls.

PAGE 2 This is one of the most important pages for including information for our billing department, and can be the deciding factor as to whether we get paid for the call. This is also the best page for you to provide your “picture” of the call and initial contact.

Page 2 You MUST select and impression Initial patient acuity shows what level of seriousness the patient presented with.

CHIEF COMPLAINT This should not be what you was dispatched to. This should be why the person called 911 You should type what the patient states or portrays as the reason they need to go to the hospital.

CHIEF COMPLAINT SICK is not a complaint. Nausea, vomiting, fever, trouble breathing. The symptons of the patient's illness are good chief complaints. Motor Vehicle Crash is not a chief complaint. Neck pain post MVC. Head pain. Back pain. All of these are why that patient needs an ambulance and ultimately, transport.

HISTORY OF PRESENT ILLNESS This area is the most crucial. The information provided in this small block is the primary information used by insurance to authorize the payment for our treatment and transport.

HPI At EAPS we have a few requirements for HPI.  Every HPI should start with the statement “Eastern Area Medic 312 responded immediately for a 911 dispatch. E0 Dispatch Code for a female unconscious. Arrived on scene to find 57yo female complaining of weakness.”  Every call that a medic is on and patient contact is made, MUST include the statement “ALS Assesment by Paramedic __________”

HPI Your HPI is the one place to start to draw that verbal picture of your call. You should include all pertinent details of your patient's condition, complaint, situation, events leading to, pertinent negatives, etc... Your treatment and activities preformed on the call do not belong in the HPI. Concider the HPI as what happen till I arrived.

Other EMS This is where you put other agencies or trucks that responded with you. Even if you list them as crew, if they came in a different truck, include that information here. If QRS responds they must be added in this section. If mutual aide companies respond they must be included.

PAGE 3 Neuro/Airway This is a first impression or what is reported to you. This should not reflect the patient's assessment at his/her best or worse. This should not include airway management done by your crew. Only procedures preformed prior to your crews arrival.

Page 4 Same as page 3. This page is first impression. Only document oxygen if it was on the patient when you arrived. Home oxygen or oxygen the facility / staff / QRS put on the patient prior to you arriving.

Page 5 As the page implies this is a reasonable place to document your assessment. You should document all findings, as well as all pertinent negatives in your assessment.

Page 6 Again this is for IVs, Medications dilivered, and drips that were given/initiated prior to you beginning care. DO NOT DOCUMENT YOUR TREATMENTS IN THIS SECTION.

Page 8 – Activity Log This section should include all activities that you and your crew preformed or took part in. This is also where you will document all qualifying documentation for meds, treatments, and care. Changes in patient condition. Observations. Anything that took part during your contact with the patient should be documented here.

Page 9 Activity audit is required to close the tripsheet. You MUST scan and attach all pertinent documentation for the call.  Run Sheet  Billing sheet with signature  Medical Necessity  Refusal You must sign your chart.

Once this is complete. I recomemd clicking “Entire Chart” view and go over your tripsheet before advancing it. Make sure you have completed all required sections. Provided all the information you needed or wanted to. For serious or involved calls we recommend that another member of the crew review the tripsheet before saving it. We do not kick charts back for changes. You will have to make an addemndum to the chart for any corrections.