It should be clear at this point that documentation is of the utmost important to the AccuMed team, as it should be for fellow billing companies and EMS providers. There are multiple aspects that go into documentation, for now we’ll focus on dispatch. As an EMS provider, your dispatch documentation has a huge domino effect down the line. This isn’t something you should just go through the motions on, these documents have clinical, legal and financial influence.
Clinical
Your documentation becomes part of the patient’s medical record. This could play a real role in getting them the proper care that they require. From first responder, to hospital all the way to any potential ongoing rehab the patient may need, this initial documentation plays a role.
A few things to remember to always include in your narrative:
Make sure it’s a full assessment. How did you find the patient? What was the chief complaint stated to bystanders, patient, other providers? Where exactly is the patient’s injury or pain?
Legal
We have a legal obligation to CMS to provide accurate, complete and honest documentation. It’s important to strive to provide a full and complete narrative for review.
Financial
Good documentation also can have financial incentive. If you’re giving your biller a complete narrative, they can code the incident properly and get you the full reimbursement your department deserves (and I’m sure desires).
While documentation might not be the most exciting or a favorite part of EMS duties, it’s definitely important. So, keep giving those full narratives so our patients can get the best care possible right from the start and our departments can be in the best possible legal and financial standing!