Guideline 1-450-33 - Documentation Reviews

CMH EMS & MIH Protocols

Scope:

Guideline:

Purpose:

Procedure:

Refer to Guideline 1-700-33 - Documenter Reference Sheet for reference and definitions.

Reviewers should look for:

• LifePak download attached?
• Facesheet and other scans attached?
• Incident tab:
• Incident number formatted correctly?
• Emergent vs. Non-Emergent accurate?
• EMD complaint and EMD Code correct? Only if EMD was used should a code be entered?
• Responding from correctly indicates the station they were assigned and aligns with run number?
• "Transport Due To" correct?
• Should be "Closest Facility" unless clinical needs made it "Protocol."
• If "Patient Choice," is there a refusal signature?
• Receiving facility chart number correct?
• Mileage looks appropriate?
• Patient tab:
• Complete history included?
• Vitals tab:
• Complete set of vital signs?
• Flowchart tab:
• If ALS provider on the crew, is "ALS Assessment" in flowchart?
• Assessments tab:
• Laterality documented and consistent?
• All treatments provided supported by assessment findings?

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• Narrative tab:
• If anything is marked UTO, has it been explained?
• Narrative includes complete DRAATT information?
• Lab value interpretations listed?
• If transfer, details of hospital visit and reason for transfer included?
• If PRC, reading the Miranda out loud documented?
• If PRC, referral documented?
• Forms tab:
• Appropriate forms been filled out?
• Acute Coronary Sydrome?
• Obstetrical?
• Spinal Immobilization Screening Tool?
• RACE Stroke Scale
• Sepsis Screening
• BEFAST Stroke Scale
• Billing tab:
• CMS Service Level correct?
• If ALS1 or ALS2, is "ALS Assessment" in the flowchart?
• Is Immediate vs. Non-Immediate selected correctly?
• If PCS transfer, is Medical Necessity and Transport completed? (Not just "higher level of care")
• Signatures tab:
• Were all signatures obtained?

Add feedback:

• Be specific, positive, and give them the benefit of the doubt.

Rating:

Send message:

• Send message for review and/or fixing by the documenter: Include their manager as a recipient of the message. Consider adding their partner, too.
• Open EHR and "unlock" the chart if the documenter needs to make changes.

Change status:

• Mark "approved" only if all the above answers are "yes" and it is ready to send to billing.

Send to clinical reviewer or peer counselors?:

• If you feel there were serious deviations from protocol, standard of care, or other concern, switch to "clinical review" and assign it to a clinical reviewer or other appropriate leader. Also, please send a Slack or Cortext to let them know to look for it.
• If you feel this call might cause stress to the staff (i.e. pediatric, family member, major trauma, etc.), please send a Slack or Cortext to the appropriate peer counselor.

CMH Pre-Hospital Services Mission: "Provide safe, exceptional, and compassionate care to our communities with an emphasis on highly trained and empowered staff."

CMH Mobile Integrated Healthcare Mission: "Provide exceptional, compassionate, and patient-centered care by a mobile collaborative team to improve patient experience, improve quality outcomes, and reduce healthcare costs."

Polk, Hickory, Cedar, & St Clair County EMS Protocols is licensed under a Creative Commons Attribution-ShareAlike 4.0 International License.