Diving a little deeper into our previous blog post on documentation, we realize there’s a lot that goes into a good report. We’d like to make that a little easier for you. Sometimes it can help to have a check list. Below is a list of some of the top things to keep in mind when documenting your ambulance runs!
When writing your report, can you answer yes to these questions:
- Do you have all dispatch information?
- Did you document the complaint at the time of the call?
- Do you have dispatch protocols readily available?
- Did you document resident status?
- Did you paint a complete picture of the patient’s condition at time of service?
- Did you get a patient signature?
- Is the date of transport clearly indicated on the ambulance trip report?
- Do you follow the CHART format?
- Do you use appropriate abbreviations?
- Are all fields filled in and all supporting documents attached?
- Is your narrative thorough?
- Did you use as much detail as possible?
If you answered yes to all the above, great! Keep doing what you’re doing. If you’re shaky on a few of these, talk to your biller and see if they can offer you or your department any documentation training. Remember, good documentation is an integral step in giving our patients the best care possible! At the end of the day, that’s the most important thing to all of us.