EMS Documentation / Edition 1

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Overview

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.
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Product Details

  • ISBN-13: 9780132369640
  • Publisher: Prentice Hall
  • Publication date: 8/15/2007
  • Edition description: New Edition
  • Edition number: 1
  • Pages: 264
  • Sales rank: 565,538
  • Product dimensions: 8.40 (w) x 10.60 (h) x 0.60 (d)

Meet 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.

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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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