Documentation Standards

["Pickering, Tim" <TPickering@medflight.com>]

None out there that I am aware of.  Local and national standards of practice
and state law will govern some of what you need to do, reimbursement
documentation will actually provide you with guidance as to what should as
well be in your chart - remember in today's world you should be documenting
for clinical, legal AND reimbursement.

PLEASE reply to the entire list so that we all can share in the knowledge!

Thanks,

Tim Pickering, JD, EMT-P
Risk Manager
Ohio Medical Transportation, Inc.
2827 West Dublin-Granville Rd.
Columbus, Ohio 43235

Office   1-877-MED-FLYT
Direct      614-734-8024
Fax         614-734-8084
Pager   1-800-428-2945
Cell         614-581-6852

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"From: Kevin Bleasdale <kevin.bleasdale@ucdmc.ucdavis.edu>
Subject: Re: Documentation Standards
Reply-To: flightmed@flightweb.com

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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