Documentation Tips 2021 Edition
Posted on: January 20th, 2021
Here are some friendly tips to improve your documentation and avoid an audit:
1. Please ensure to document CPR ratios (pre and post application of the King LT)
2. Please document your rhythm interpretation, 12 lead or cardiac monitor.
3. Please document a pain scale (for nitro administration or analgesia) helps better understand the clinical presentation.
4. Please document your rhythm interpretations during an arrest, it may be vital.
5. Please remember to patch to the BHP after the 3rd analysis or after the 3rd round of Epinephrine in the Medical Cardiac Arrest.
6. Please remember to document your patch failures 402 or 403 with a brief description in the result.
7. Always remember what is “Benefitting your patient!”