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EMS Documentation, CourseSmart eTextbook

By John Snyder

Published by Prentice Hall

Published Date: May 16, 2008

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Description

Proficiency in documentation is vital to protecting and advancing the careers of EMS professionals as well as to meeting today’s challenges in the industry of EMS.  EMS Documentation is a worktext designed to improve documentation skills for those at all levels of prehospital provider training.  Whether you are new to EMS or have years of experience, this book will help improve competence and confidence in providing complete, clear, and accurate documentation of patient care.

Table of Contents

Chapter 1       Documentation: What’s in it for You?

Key Ideas

Case Study

Questions

Introduction

Key Terms

The Evolution of EMS

Challenges Facing EMS

EMS Documentation

            Your Practice Before a Large Audience

            The Mirror of Your Professionalism

            Your Most Important EMS Skill

            Protecting Your Career

            Your Quality of Life

Summary: Return to Case Study

Chapter Review

            Review Questions

            Critical Thinking

            Action Plan

            Practice Exercises

           

Chapter 2    Documentation and Professionalism

Key Ideas

Case Study

Questions

Introduction

What is EMS? 

Who Speaks for the EMS Profession?

Who Regulates the EMS Profession?

Key Terms

 

Defining the EMS Profession

The History of the EMS Profession and Documentation

            The Early Years-EMS in the 1960s and 1970s

            The Transition Years — EMS in the 1980s and 1990s

            EMS Today

Advancing the EMS Profession — Research and Documentation

Advancing the EMS Profession — Quality Management and Documentation

Summary: Return to Case Study

Chapter Review

            Review Questions

            Critical Thinking

            Action Plan

            Practice Exercises

           

Chapter 3        Documentation and the Financing of EMS

Key Ideas

Case Study

Questions

Introduction

Key Terms

The Financial Challenge of EMS

             EMS Funding — Past and Present

Documentation and Reimbursement

The EMS Billing Process

Medicare Basics

            Medical Necessity

            Medical Review

            Medicare Denials

Summary: Return to Case Study

Chapter Review

            Review Questions

            Critical Thinking

            Action Plan

            Practice Exercises

 

Chapter 4    Legal Responsibilities and EMS Documentation

Key Ideas

Case Study

Questions

Introduction

Key Terms

Legal Challenges in EMS

Public Accountability — Civil and Administrative Law

            Legal Structure

            Legal Process

            Civil Law — Negligence and Malpractice

            Negligent Documentation

            Administrative Law

            Scope of Practice

            Standard of Care

Governmental Accountability

            The PCR and HIPAA

            The PCR and EMTALA

            The PCR and the False Claims Act

Summary: Return to Case Study

Chapter Review

            Review Questions

            Critical Thinking

            Action  Plan

            Practice Exercises        

 

Chapter 5  Documentation Fundamentals

Key Ideas

Case Study

Questions

Introduction

Key Terms

The Five “Cs” of Clinical Documentation

EMS Documentation Basic #1 - Clear

                        Abbreviations

                         EMS Jargon

EMS Documentation Basic #2 - Complete

EMS Documentation Basic #3 - Correct

                        Spelling and Grammar

Correcting Errors or Omissions

EMS Documentation Basic #4 - Consistent

EMS Documentation Basic #5 - Concise

Summary: Return to Case Study

Chapter Review

            Review Questions

            Critical Thinking

            Action  Plan

            Practice Exercises

 

Chapter 6 Essential Documentation Elements  

Key Ideas

Case Study

Questions

Introduction

Key Terms

EMS Event Summary Data

            Event Times

            Demographic Data

            Financial Information

Assessment Summary Data

            Scene Data

            Situation Data

            Injury Data

            Cardiac Arrest Data

            Medical History

Assessment and Physical Examination

            Trauma Assessment

            Focused Physical Examination

Treatment and Interventions

            Airway Procedures

            Cardiac Monitoring and Interventions

            IV Therapy

            Medication Administration

            Safety Interventions

Affirmation

            Medical Necessity

            Transfer of Care

            The Narrative

            Signatures

Summary: Return to Case Study

Chapter Review

            Review Questions

            Critical Thinking

            Action  Plan

            Practice Exercises

 

Chapter 7 Narrative Documentation

Key Ideas

Case Study

Questions

Introduction

Key Terms

Narrative Fundamentals

Traditional Documentation and Narrative Formats

            SOAP Format or SOAPIER

            CHARTE Format

            Head-To-Toe Format

            Body Systems Format

The EMS Focused Event Summary

Summary: Return to Case Study

Chapter Review

            Review Questions

            Critical Thinking

            Action Plan

            Practice Exercises

 

Chapter 8        Medical Necessity 

Key Ideas

Case Study

Questions

Introduction

Key Terms

Medical Necessity Ground Rules

Medical Necessity       

            Emergency Coverage Guidelines

Non-Emergency Coverage Guidelines

Documentation and Medical Necessity

Medical Necessity — Essential Documentation Elements

            Demographics

            EMS Diagnosis

            Past Medical History

            Assessment and Interventions   

            EMS Event Summary - Narrative

            Signatures

            The Medical Necessity Statement

The Medical Necessity Statement

Writing the Medical Necessity Statement

Medical Necessity Considerations for Emergencies

Medical Necessity Considerations for Non-emergency Interfacility Transports

The Physician Certification Statement (PCS)

            The Advance Beneficiary Notice (ABN)

 

Medical Necessity Considerations for Air Transports

 

            Considerations for Scene Flights

            Considerations for Interfacility Air Transports

Ethical Considerations for Medical Necessity Documentation

Summary: Return to Case Study

Chapter Review

            Review Questions

            Critical Thinking

            Action Plan

            Practice Exercises

 

Chapter 9        Putting It All Together

Key Ideas

Case Study

Questions

Introduction

Key Terms

The EMS Documentation Process

Time Management and EMS Documentation

The Impact of Assessment Skills in EMS Documentation

            The Medical History

            Assessment and Examination

Making a Commitment

Summary: Return to Case Study

Chapter Review

            Review Questions

            Critical Thinking

            Action Plan

            Practice Exercises — Role Play

 

Chapter 10   Patient Refusals

Key Ideas

Case Study

Questions

Introduction

Key Terms

Legal Principles and the Patient Refusal

            The Patient Refusal and Duty to Act

            The Patient Refusal and Capacity and Competency

            The Patient Refusal and the Right to Self Determination

                        Informed Consent

                        Implied Consent

                        Involuntary Consent

The EMS Refusal Interview

            A - Assess:  Assessment of Condition, Capacity, and Competence

                        Condition

                        Capacity and Competence

                        Physical Assessment

E - Educate     

            I — Inform

            O - Offer Transport

            U — Understand: Validate Understanding

The EMS Refusal Documentation Process

             C.A.S.E  C.L.O.S.E.D - Patient Refusal Narrative Documentation

                        C = Condition, Capacity, and Competency

                        A = Assessment

                        S = Statements Made by the Patient

                        E = Educate

                        C = Consequences

                        L = Limitations of EMS

                        O = Offer Transport

                        S = Signatures and Initials

                        E = Educational Material

                        D = Dial 911 Again

Summary: Return to Case Study

Chapter Review

            Review Questions

            Critical Thinking

            Action Plan

            Practice Exercises

 

Chapter 11 Incident Reporting

Key Ideas

Case Study

Questions

Introduction

Key Terms

The Purpose of Incident Reporting

The Five Rights of Incident Communication

            The Right Form

            The Right Facts

            The Right Focus

            The Right Forum          

            The Right Follow-Up

General Guidelines for Internal Communication

Summary: Return to Case Study

Chapter Review

            Review Questions

            Critical Thinking

            Action Plan

            Practice Exercises

 

Chapter 12 Verbal Reports

Key Ideas

Case Study

Questions

Introduction

Key Terms

Legal Issues and Verbal Reporting

Verbal Reporting and the PCR

The Pre-Hospital (Radio) Report

            Reporting to the Physician

            Pre-Hospital Report Format

The RN Transfer of Care Report

            Reporting to the RN    

            Guidelines for Transfer of Care Reporting

            RN Transfer of Care Report Formats

Summary: Return to Case Study

Chapter Review

            Review Questions

            Critical Thinking

            Action Plan

            Practice Exercises — Role Play

 

Chapter 13 Complex Patient Encounters

Key Ideas

Case Study

Questions

Introduction

Key Terms

EMS Documentation and the Crime Scene

            General Principles of Crime Scene Documentation

                        The Sexual Assault Victim

                        The Child Abuse Victim

                        The Elder Abuse Victim

EMS Documentation and the Behavioral Crisis

            The Suicidal Patient

EMS Documentation and the Rights of Patients

The PCR and the Advance Directive

Summary: Return to Case Study

Chapter Review

            Review Questions

            Critical Thinking

            Action Plan

            Practice Exercises —Role Play

 

Appendix

Patient Care Report (PCR)

 

 

 

 

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