ACR (comments) writing

[CBEMT]

"My partner did this while I did that." "Assisted in getting her seated." Who cares? WAY more info in there than there needs to be.

"Pt found seated in chair AO x 4/4. Pt c/o mechanical fall from standing --> floor [secondary to symbol] dizziness. 1" lac R anterior scalp. Wound flushed/dressed. Vitals as noted. Pt-->stretcher-->truck-->ED [without] incidents or [change]."

Done. Six lines condensed down to two and a half, and much more professional-sounding to boot.

Granted I typically document more than that for such a call (a few more assessments, plus pertinent negatives and such), but if I was going to write what you did, that's how its done.

[AmrEmt]

Thanks!

The only reason I state how the pt got to the gurney is because my FTO would ask me "and what, she walked to the ambulance and got in and seated herself??" and tho *I* didnt think its really pertinent unless the pt is immobile, i now put that down whether she walked to the gurney, we manually maneuvered her, or what. Good idea on the vitals, ill do that next time for sure, as well as shortening the treatment stuff on the lac!

Caryn

[Ridryder 911]

Remember the purpose(s) of charting. First it is a legal documentation (charting) of what you found, assessed, treated/intervention, and evaluation, and plan. Second, where most do not understand, it is for billing purposes as well. This is the reason for documenting if they were non-ambulatory, bed ridden, etc.. If it is not documented and paint a picture that stretcher or treatment/monitoring required, chances are your EMS is not going to be reimbursed for their services. Thus, what does not come in does not go out.. = no pay, no raises, etc.

My suggestion is to look at your company protocol and manual. Each should have an approved medical abbreviation(s) and format. This is what the attorneys and legal system will examine. Each hospital has an approved medical terminology and abbreviation list, this prevents people making up their own. If you don't have one, I suggest to discuss with the administrator to develop one.

Look at charting and documentation of others. Charting and documentation is an art, and skill like any other skill in EMS. I personally document my physical examination similar to a physician, including pertinent negatives to prove that I did assess and evaluate or rule out, as well as in-depth follow up. I also include time & whom, I made any type of verbal report per cell phone , etc.

R/r 911

[CBEMT]

The only reason I state how the pt got to the gurney is because my FTO would ask me "and what, she walked to the ambulance and got in and seated herself??" and tho *I* didnt think its really pertinent unless the pt is immobile, i now put that down whether she walked to the gurney, we manually maneuvered her, or what.

I'm surprised they really want you to be that specific, because walking to the stretcher (or walking to the ambulance) means you aren't getting paid by Medicare for that run. But hey, if they REALLY want you to, by all means. If they're like a local company here that hands back unpaid run forms to be re-written, tell them to kiss your ass.

My favorite is when the college we go to walks two drunks to the truck and wants us to take both. Company "policy" is that nobody walks, ergo you have no reason to document that somebody walked to the truck- everybody gets the stretcher. Ok, so how am I supposed to document that I transported two different people to on the stretcher at the same time? Granted these kids don't have Medicare, but still.

[MAGICFITZPATRICK]

In my opinion this has to be one of the "best" written threads I have ever see on EMT CITY.I can use just about everything from every one of these posts.

[jwraider]

I have a format I follow for interfacility transfers:

1) State where we arrived and who we found: "XYZ unit AOS @ sending facility to find X y/o male/female pt supine in bed"

2) State how pt presents: "Pt presented AOx4, C/O L hip pain, 6/10. Pt obese (130kg) , agitated, diaphoretic"

3) State why the pt was admitted + what important drugs they are on: "Pt admitted D/T L hip pain / secondary to hip FX from mechanical fall. Pt given 5mg Morphine by sending facility."

4) State how we moved the pt including info showing why an ambulance is req for transfer: "Multiple attendants req to carefully slide pt to/from gurney"

5) State what we provided pt and what happened during transfer with more reason for transfer: "En route monitored vitals (166/90, 86 , 16) provided orthopedic wedge between legs.Pt is HTN C/O of L hip pain 8/10 with Hx of CHF."

6) State where we took them and why: "Transferred to recieving facility for XRAY of L hip/leg, service not provided at sending facility."

End Result:

XYZ unit AOS @ sending facility to find 75 y/o male pt supine in bed. Pt presented AOx4, C/O L hip pain, 6/10. Pt obese (130kg) , agitated, diaphoretic. Pt admitted D/T L hip pain / secondary to hip FX from mechanical fall. PT given 5mg Morphine by sending facility. Multiple attendants req to carefully slide pt to/from gurney. En route monitored vitals (166/90, 86 , 16) provided orthopedic wedge between legs. Pt is HTN C/O of L hip pain 8/10. Hx of CHF,ETOH,Arthritus. Transferred to recieving facility for XRAY of L hip/leg, service not provided at sending facility.

[JakeEMTP]

I'm surprised they really want you to be that specific, because walking to the stretcher (or walking to the ambulance) means you aren't getting paid by Medicare for that run. But hey, if they REALLY want you to, by all means. If they're like a local company here that hands back unpaid run forms to be re-written, tell them to kiss your ass.

My favorite is when the college we go to walks two drunks to the truck and wants us to take both. Company "policy" is that nobody walks, ergo you have no reason to document that somebody walked to the truck- everybody gets the stretcher. Ok, so how am I supposed to document that I transported two different people to on the stretcher at the same time? Granted these kids don't have Medicare, but still.

I am somewhat but not totally shocked that you would not document exactly what happened. If your pt. walked to the stretcher or to the ambulance, than that is what you document. If your employer doesn't get paid for the run, than so be it. But to actually and obviously omit something is just plain fraud.

[CBEMT]

I am somewhat but not totally shocked that you would not document exactly what happened. If your pt. walked to the stretcher or to the ambulance, than that is what you document. If your employer doesn't get paid for the run, than so be it. But to actually and obviously omit something is just plain fraud.

I prefer to write my run forms once. If I document no-pay criteria, I'm going to be told to re-write it.

It's the re-write that would be fraud.

[JakeEMTP]

I prefer to write my run forms once. If I document no-pay criteria, I'm going to be told to re-write it.

It's the re-write that would be fraud.

If you document the first time what exactly happened, you shouldn't have to re-write it. If you change it to include something else, than you are correct, that would be the fraud. However, including something in your original ACR that did or didn't happen is also fraud.

[CBEMT]

If you document the first time what exactly happened, you shouldn't have to re-write it. If you change it to include something else, than you are correct, that would be the fraud. However, including something in your original ACR that did or didn't happen is also fraud.

You're right, I shouldn't have to. However, documenting that someone walked to the truck, for example, would be to admit a violation of company policy- "nobody walks." Of course, management could really care less whether the patient walks or not, they know the kinds of idiots we deal with. They just don't want us documenting it, because that costs them money. So they invent a punishable offense around it for use if somebody really insists on being a problem for them.

If I don't play the game, I run the risk of being fired- and having to find employment at another private company with the same rules. Me personally, I'd rather keep my seniority than bounce from company to company until there aren't any left that I don't have a reputation at.