Re: Documentation Standards

[Kevin Bleasdale <kevin.bleasdale@ucdmc.ucdavis.edu>]

Hi,
	I have never seen any national standards for documentation - something of
a puzzle, huh? Would you please forward any information you get on
standards to me? 

Thank you,

Kevin

>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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