Designed for clinicians working in emergency services, the course will cover skills needed to reduce provider liability, improve clinical narratives, facilitate accurate billing, and improve EMS agency legal compliance.
This article was originally published on July 6, 2017, on the Association of Clinical Documentation Improvement Specialists.
Proper documentation from ED physicians and EMS services can be extremely helpful for the inpatient record, formulating queries, and painting a complete clinical picture of the patient’s condition. Whether or not that documentation provides a complete picture, is a totally different story.
Starting in October, however, the National Academy of Ambulance Compliance (NAAC) will offer the first ever EMS documentation certification to ensure the emergency personal document the clearest, most accurate, and most complete record possible on arrival at the facility. Those who pass the course will earn their Certified Ambulance Documentation Specialist (CADS) credential.
The course will cover essential documentation skills needed to facilitate high quality patient care, reduce provider liability, improve clinical narratives, facilitate accurate billing, and improve EMS agency legal compliance, according to the Journal of Emergency Medical Services.
The course takes approximately five to six hours to complete with a written exam at the conclusion. It covers the following topics:
- EMS documentation framework
- Documentation fundamentals
- Documentation of special situations, such as patient consent, refusal, etc.
- Writing an effective clinical narrative, including a discussion of CDI in particular
- Documentation and compliance
- Medical necessity and reason for transport
- Signature requirements
The certification will help to open new doors for those in working in the EMT field, advance their career, and improve their status as a healthcare professional, according to the NAAC website.
The first course will be offered on October 27 in conjunction with the abc360 conference in Hershey, Pennsylvania, and will be offered at all subsequent abc360 conferences in 2017. Starting in 2018, the course will be offered online through NAAC.
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