Top 10 Documentation Mistakes Ambulance Providers Make – and Supervisors Overlook
Conclusions or Stating “Opinions”
You must document objectively, not subjectively, what you observe.
Use good charts/processes to keep you on track:
O.P.Q.R.S.T.
Onset
Provocation
Quality
Radiation
Severity
Time
D/R.A.A.T.T.
Dispatch
Response
Arrival
Assessment
Treatment
Transport
C.H.A.R.T.
C = Chief Complaint
H = History (Past & Present)
A = Assessment
R = Rx or Treatment
T = Transport and conditition enroute
Mistake #4: Internal Inconsistencies
There can't be inconsistencies in the narrative. For example, if you check off both “normal” and “amputation” on an anatomical chart, or describe it differently in your narrative – you will raise red flags with reviewers, payors or lawyers.
Mistake #5: Improper Addendums or Corrections
Wirth noted that it's the provider’s duty to make accurate, honest added addendums/notations to make sure your PCRs/narratives are accurate.
First and foremost, any corrections must be true, accurate and honest!
Never change documentation just to get a claim paid. However, you need enough documentation to allow a determination to be made as to whether it should be made, and at what level of service.
If you miss something important and think of it later, attach an addendum sheet and state why you are attaching it. (E.g., "We didn't know this information at the time of transport,” or, “On the original report, we failed to note that oxygen was administered.")
Remember that it's OK to make documentation mi...
Source: JEMS Special Topics - Category: Emergency Medicine Authors: A.J. Heightman, MPA, EMT-P Tags: Exclusive Articles Documentation & Patient Care Reporting Source Type: news
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