Documentation

Documentation paints the picture of what happened in a call​​

• Patient’s baseline status ​​
• Rationale for treatment provided or withheld​​
• Changes in condition with treatment rendered ​​
• Changes in condition necessitating further interventions or actions 

​You May Recall… 

• As highlighted in a previous SWORBHPTip, in cardiac ischemia the priority of investigations and treatment are important (a 12-lead ECG and consideration for ASA should occur before nitro administration). Your documentation should reflect this temporal sequence and prioritization. ​

• Remember, your documentation paints the picture of what happened! 

Documentation​

​Some key procedure codes & potential sequence:​​

• 020 Patient Assessment​​
• 010 Vital Signs – Include Pain Scale (Baseline)​​
• 504 ASA 160/162 mg PO​​
• 313 12-Lead – Include Interpretation​​
• 298  Defibrillation – Pads On​​
• 615 Nitroglycerin 0.4 or 0.3 mg SL, q 5 min​​
• 010 Vital Signs –Including Pain Scale (Post medication administration)

Bottom Line:

Documentation is important in all calls to “paint the picture” of what happened.​​

 In suspected cardiac ischemia calls this should include what assessments, investigations and interventions were performed (and when) as well as any supporting rationale for these decisions.

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No additional resources available for this #SWORBHPTip.