Which style should I use? What are documentation styles?
Ambulance service is an integral and essential part of the healthcare continuum. Effective ambulance service organizations are built on the foundation of excellence in patient care.
This documentation guide is designed to serve and strengthen that foundation by allowing for accurate, consistent and relevant patient care documentation throughout the prehospital and out-of-hospital experience.
Documentation serves many functions for healthcare organizations. Primarily it serves to memorialize the patient interaction and to communicate all aspects of that interaction to other healthcare professionals caring for the patient.
It also serves as a basis for continuous quality improvement CQI activities, regulatory compliance initiatives, governmental reporting, research requirements, risk management and reimbursement Systems documentation techniques essay.
The healthcare environment of the 21st century demands from ambulance services and other healthcare providers a higher and more consistent quality of documentation.
In their book, Nursing Documentation: A Nursing Process Approach, P. Camp state the following: Documentation has assumed new importance with the current emphasis on monitoring the quality of health care as evidenced by patient outcomes.
When financial resources were abundant and good care was assumed to be inherent, the evaluation of care was left to healthcare professionals, or no evaluation was done. Prospective payment systems and limited healthcare resources have made the quality of healthcare a major issue.
Consumers, insurers, and government agencies are seeking more information on clinical performance and related dimensions of good care. The American Ambulance Association has developed this comprehensive documentation guide to help ambulance service organizations gather and submit the kind of information consumers, payors and agencies are looking for.
The guide is designed to help ambulance service organizations and EMS training programs train their personnel and students in the appropriate and required documentation standards.
It is also designed to help communications, reimbursement and other operational personnel understand their roles in gathering the necessary documentation and how this documentation fits with information from the field.
The guide is appropriate for use in new-employee orientation programs, as well as in the yearly updates needed to meet federal compliance training requirements. In fact, a clearly articulated documentation-training guide is fundamental to the compliance programs required of all ambulance services that bill Medicare.
It may also help educate those people who receive and track documentation, such as government regulatory agency employees and ambulance service payors.
The documentation guide focuses primarily on the core data elements that must be captured for every ambulance service call. The data is divided into the following three general areas: Communications, ambulance, and reimbursement personnel all have roles to play in capturing the necessary information for all three data categories.
The role of individual employees in recording information in any given organization is often system-dependent. Thus it is important for all three personnel groups to know the extent of the information they will need to obtain to ensure that all necessary documentation is completed.To create paragraphs in your essay response, type.
at the beginning of the paragraph, and. at the end. Even with electronic documentation, we still need to perform the diagnostic procedures carefully and input the information correctly. Regardless of the system you use, document information thoroughly in a secure, legible, and organized manner.
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