Documenting Incidents for Public Places/Stand-By Events
We are asked…
Here at the billing office we often are asked questions about documenting EMS incidents that take place in public places and many times during stand-by events.
There are the events where your EMS agency is engaged such as high school sporting events, community events such as festivals, marathons, celebrity and public official speaking engagements and can also involve direct or indirect attendance by your staff at places of public gatherings such as churches, club activities and the list goes on and on.
Special Attention
Special attention must be paid to these events because they are atypical. However, the basics of documentation still apply. Whenever EMS providers are providing assessment and/or treatment of injuries or illnesses and regardless of the setting, it is vitally important that there be documentation to chronicle the event in the most sufficient detail. Plus, if the patient is transported then it is even more vital that the initial caregiver provide information to document the scenario as only that person providing the initial care can document the beginning stages of assessment and/or treatment for that incident.
We tend to…
We tend to think of stand-by events or incidents that happen while we may not directly be on duty as less important.
This is a danger.
When we leave our guard down, those are the times when it seems problems arise and we have not covered ourselves as EMS providers by documenting incidents appropriately. This affects not only potentially being reimbursed for the incident, but also can include potential adverse legal ramifications if something, God forbid, goes wrong as part of the scenario.
Written Notes
Be sure you always have written notes regarding your incident. It is important to have written information about the unusual event that took place. If you eventually transport your patient then it is important to pass on those notes to the transporting agency once they arrive to insure continuity of care. Of course, if you wind up being the EMS provider that “rides in” with the patient who is transported, now those notes become part of your Patient Care Report preparation.
Of course, always identify your patient appropriately by gathering all of the necessary demographic information in addition to documenting the injury or illness and the assessment and treatment of the injury or illness.
Document your status…
Of course, it is important to document your status for the event. If your EMS agency is on stand-by then it’s important to document it. Many regions across the United States require the stand-by crew to contact the 9-1-1 center for an official dispatch, especially if additional resources are required (police, fire, additional EMS such as a need for an upgrade of care such as an ALS intercept, etc.)
Be sure to document how you became aware of the incident, when 9-1-1 was contacted and how you “responded” given the stand-by situation.
Maybe you were attending an event not directly covered by the EMS agency you are affiliated with and a medical or traumatic injury emergency took place during the event. You arose to the occasion and helped with assessing the patient and/or treating the patient and now you need to recall the facts of the event in writing. Be sure to follow the same guidelines you would follow as if you were actively in the field and part of the responding EMS crew.
Other Documentation
There are times when during a stand-by event, the patient refuses transport. You may treat the patient and the patient resists any further treatment beyond your summary acts at the scene. Be aware of your State’s rules and regulations concerning documented refusal scenarios, such as if you are required to contact a command physician for release of liability, especially if the patient is acting against your advice as a healthcare professional.
In addition, many organizations such as sporting arenas, schools, churches, places of business have a requirement that they be notified and information to be collected as part of the rules of that particular venue so they are aware of illnesses and injuries that take place on the premises. It is important to know these rules and follow directives as long as those directives are in line with HIPAA privacy and other confidentiality statutes.
Know what forms may be required as part of the scenario, as well.
The venue’s directives may also figure into the reimbursement picture so be aware if information must be passed on to the venue for reimbursement by the venue or an eventual bill going out to a third-party insurance payer.
