EMS Documentation
Published on 12. May 2008
Book
Paperback/Softback
264 pages
978-0-13-236964-0 (ISBN)
Description
WorkText on documentation, or PCR (patient care reports) writing. Contains legal and business implications of improper documentation, paper and electronic documentation processes, and lots of practice exercises. An in-text CD will include several PCR versions, and audio glossary (for proper terminology and pronunciation), and additional exercises.
More details
Person
John Snyder is an EMS consultant specializing in education, program, and staff development and reimbursement matters. A graduate of Creighton University's Paramedic Training Program in Omaha, Nebraska, and Rogers State University in Claremore, Oklahoma, John has been in EMS for 25 years. John has a strong clinical foundation, with over 22 years of EMS practice, and has served as a paramedic program instructor, field and communications supervisor, education manager, director of operations, critical care RN, and as a member of the medical review management team of one of the nation's largest Medicare Part B carriers.
Content
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)
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)