Test your Medical Legal knowledge in the April 2010 EMS1.com game. I wrote the quiz questions that were uploaded into the C3Softworks game Bravo. Games are an effective tool for teaching in the classroom and online.
Tips for electronic patient care report documentation:
1. Consistently work through each data entry screen. The software set-up might not always be the most logical.
2. Confirm the patient’s mailing address as it may be different from the pick-up location or where the patient is currently residing.
3. Carefully enter patient demographic information, like name, birth date, and social security number, so it synchronizes with information already on-file about the patient.
4. Use the body diagram to annotate injury locations, previous injuries, and medical devices (likeostomy site, pacemaker location, central line port, feeding tube, medication patch, or urinary catheter). You can also mark the location of successful and unsuccessful IV sites.
5. Use a medical documentation technique like SOAP or R-CHART for the patient care narrative.
6. Spell check and re-read the narrative before submitting. Also check your notes one more time before finalizing
7. Always review any hand-written notes one final time before synchronizing the ePCR with the data server. I almost always find some additional details that I want to include in the narrative.
Remember, the ePCR is a reflection of your skills, knowledge and professionalism. Use it to showcase your talent, the careful assessment you performed and the compassionate interventions you delivered to the patient.
What about your medical legal questions? Do you have any documentation tips? Share them in the comments area below!