Emergency Medical Service (EMS) providers often feel that documentation is a tedious, time-wasting practice, but it can save lives and jobs. Correctly filling out patient care documentation helps people track and review care for a patient when they receive emergency services. Various factors should be present in EMS documentation.
A patient care report (PCR) is an essential legal document, but it is never as important as patient care and safety. Visit this page to read our guide for improving patient safety.
Let’s look at some elements that should be present in any EMS documentation.
Documenting patient arrivals is crucial because it helps give a time of transport and shows if symptoms change between treatment and transport. It’s also essential to note pre-hospital care since some health insurance providers will argue the necessity of treatment based on symptoms. If the PCR shows the presence of pre-hospital care, it proves the treatments’ validity.
Documenting comorbid conditions helps build links to presenting symptoms and helps to support the validity of treatments given to the patient. It also provides a basis to build a diagnosis during later analysis. Saying that a patient has a history of specific symptoms and conditions gives more information to the EMS crew than just listing current symptoms.
Impressions of the Patient and Treatment
Always document your impression of the patient, the diagnosis, and how you arrive at the diagnosis. This process helps keep the medical team on track throughout the treatment process and helps prove the value of treatment for the patient.
Always make sure to include vital signs for patients. Proper documentation of vital signs helps to gauge the improvement of patients and determines if any extra medical interventions will help improve their condition when and if it worsens.
Doctors and clinics sometimes send patients directly to the emergency room for care for specific conditions. Noting a referral will help prove the validity of the situation to health insurance providers. It will also help later during any follow-up care needed for the patient.
Diagnosis and Transfer of Care
The final diagnosis is crucial for proper EMS documentation. This diagnosis, combined with lab results, treatment data, and vital signs, helps paint a picture of the nature of the condition and necessary treatment for your patient. It is definitive proof of the necessity of your team’s treatment.
After that, document where you send the patient for any necessary follow-up care. That helps start the documentation process for the next healthcare provider.
Proper Documentation is Key
Proper EMS documentation is essential. Without it, an EMS crew won’t be able to prove any intervention or care used to help the patient. Always make sure the above elements are present in any patient care documentation.
Proper documentation is vital for other things, like mental health care or billing. For help refining your billing process, visit this page for mental health billing and collection tips.
At PracticeForces, we offer multiple services that can help streamline your healthcare processes. Call us at (727) 499-0351 to ask about our vast range of services.