Documentation Standards

["Deltieure, Genevieve" <GDeltieure@Virtua.ORG>]

Hi,

During a recent staff meeting the subject of documentation standards for the
air medical field came
up.  Presently, our helicopter medivac program follows the in-house policies
of the hospital that 
manages the medical end of operations.

I agreed to look into what the documentation policies other helicopter
programs have and if there is 
such a thing as national standards for documentation for the air medical
field.  Areas that were 
most questioned were things such as how frequently are vital signs
documented on a stable medical
or trauma patient on interhospital transports, and the necessity to write
out all medications given 
in both the narrative and in the flow chart, as well as the necessity to
document the time of contact 
of medical control by the flight crew.

Does any one know if there are written policies regarding documentation that
can be considered the 
standard of care in the air medical community?  If so, where can I get
copies?  If not, would other 
programs be willing to share their documentation policies with us so that we
can consider them in 
revising our policies? Any QA policies would also be appreciated.

Thank you in advance for any information you can give me.  I can be
contacted via email at:
www.gdeltieure@virtua.org , by phone at: (856) 325-4880, 7am - 7pm EST, or
at the address below.

Sincerely,

Genevieve Deltieure RN, MICP, FN
SouthStar Air Medical Program
523 Fellowship Road, Suite 270
Mt. Laurel, New Jersey 08054



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