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Charting.....Transcription or Trouble?
14 Replies

I would appreciate comments about the following charting practice: Crews at a busy private ambulance company write a paper chart at the time of the call. Upon return to the station, only some of the…Continue

Tags: legal, liability, reports, emsCharts, charting

Started this discussion. Last reply by Jim Aug 2, 2010.

 

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Jim replied to Jim's discussion Charting.....Transcription or Trouble?
"Thanks to all who took the time to comment. Your opinions were valued and helpful!"
Aug 2, 2010
Duncan Hitchcock replied to Jim's discussion Charting.....Transcription or Trouble?
"Though it would easy to negatively comment on the issue described above, not knowing the full story from all aspects it would be a disservice to all involved. Therefore, I can only comment in general as to the needs of effective and mandated patient…"
Jul 31, 2010
Skip Kirkwood replied to Jim's discussion Charting.....Transcription or Trouble?
"The world of physician transcription has changed in the last few years. Ours now dictate their narratives directly in to the eMR using a Dragon Naturally Speaking interface. Must be done before they complete their shift, as it is part of the record…"
Jul 30, 2010
Neil White replied to Jim's discussion Charting.....Transcription or Trouble?
"EPCR's are relatively new to our practice. We're on the Medusa Siren system, as a UK wide contract mainly because it needs to interact with many other healthcare systems. So on scene we can access the patients entire medical record from…"
Jul 30, 2010
Daved van Stralen replied to Jim's discussion Charting.....Transcription or Trouble?
"If they are going to use physicians as an example they should do it properly. Transcriptions are made from a dictation, all the words belong to the physician. The physician then must review the transcribed record and sign it. For electronic records…"
Jul 30, 2010
Jim's discussion was featured

Charting.....Transcription or Trouble?

I would appreciate comments about the following charting practice: Crews at a busy private ambulance company write a paper chart at the time of the call. Upon return to the station, only some of the charts are entered into emsCharts by the crew on the call. Other charts are entered by office staff, or an EMS person not on the call. When the chart is entered into emsCharts by a third-party, that individual is recorded on the chart as a crew member. Management claims this practice is necessary…See More
Jul 30, 2010
Joe Paczkowski replied to Jim's discussion Charting.....Transcription or Trouble?
"Simple. Is the transcription verbatim (word for word, check box for check box) and does the field crew review and sign off on the final transcription? Yes. No real problem. No. Do not pass go. Do not collect $200. Listing the transcriber as a…"
Jul 30, 2010
John Gaines replied to Jim's discussion Charting.....Transcription or Trouble?
"Big big problems. Especially if you end up on the stand. Something like this: Lawyer: Mr. Smith, you were the paramedic on this call? Mr.Smith: That is correct. Lawyer: Mr. Smith, we have two copies of the chart from that night. One, hand written…"
Jul 29, 2010
K C Nickels replied to Jim's discussion Charting.....Transcription or Trouble?
"We use Intermedix. This program allows us to deliver a draft report to the hospital with the basic information. It has DRAFT all over it. We can then follow up with a completed report. And of course we can add in addendums once completed. If I have…"
Jul 29, 2010
Skip Kirkwood replied to Jim's discussion Charting.....Transcription or Trouble?
"I'd reiterate what everybody has already said, and add one more. The lawyer in me (old but real) says that having two different records about the same call is a legal disaster waiting to happen. Even benign discrepancies between the two have…"
Jul 29, 2010
Chris Turner replied to Jim's discussion Charting.....Transcription or Trouble?
"Everyone is right on the button with this one: Listing a crew member on the chart is saying they were there for pt contact. Put them on there, but list them as a transcriber or something. If the comepany can afford to pay someone to transcribe,…"
Jul 29, 2010
Earl Culvey replied to Jim's discussion Charting.....Transcription or Trouble?
"This all sounds like big TROUBLE. Charting is one of the most hated functions in EMS. I hate it too, but it is a neccessary evil. I do often have my EMT partner enter demographics and other basic info for my charts on busy days. I do check for…"
Jul 29, 2010
Jim replied to Jim's discussion Charting.....Transcription or Trouble?
"Another factor is labor. The crews are already on the clock. If the service can afford to pay three or four individuals to enter charts for others, why not just have them enter the data into a billing program and eliminate the billing company. Seems…"
Jul 29, 2010
Jim is now friends with Greg Howard and EMS BILLING
Jul 29, 2010
The Cannulator replied to Jim's discussion Charting.....Transcription or Trouble?
"There should't be a need for a third party transcribing. My call. My Chart. It has a billing section. When I'm finished with it, the case is locked. Anyone transcribing should not be listed as crew but as a medical transcriber. The only…"
Jul 29, 2010
Bob Kellow replied to Jim's discussion Charting.....Transcription or Trouble?
"The private ambulance company in question has a huge problem, and by extension, the crews who are participating in this practice. I would love to be a ZPIC (Zone Program Integrity Contractor) auditor of their pre- and post payment claims. Great…"
Jul 29, 2010

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