EMS Documentation

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.

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)        

About the Author :
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.