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The program is designed to provide a broad understanding of the rules and standards for EMS documentation and then dive into the skills needed to meet those expectations. All participants in the CADS course must complete the training as well as the written final exam.
Lesson 1: The EMS Documentation Framework
In the introduction to the CADS course we will explain the purposes of EMS documentation, how it’s used in court and the proper way to amend a Patient Care Report (PCR).
Lesson 2: Clinical Narratives
In this lesson, we will discuss a variety of PCR formats, how to construct an effective narrative, the essentials of clinical and operational compliance and the importance of patient privacy.
Lesson 3: Documenting Consent, Refusals and Special Situations
This lesson deals with unique situations such as; patient consent, refusals and dealing with law enforcement.
Lesson 4: Clinical Reimbursement Information
In lesson 4, we will discover what Clinical Documentation Improvement (CDI) is and why it’s important. We will also review documentation requirements for common patient care situations.
Lesson 5: Documenting Medical Necessity
This lesson examines the role of documentation in the compliance process as well as the importance of specificity, completeness and accuracy to support proper level of service billing.
Lesson 6: Documenting the Reason for the Transport
Here we will dive into what medical necessity really means and how to appropriately document patient condition, treatment and interventions, and the reason for transport.
Lesson 7: Signatures
Last, but not least we will discuss the necessity of obtaining a patient signature for every transport. We will also cover the reason for crew signatures, the requirements of valid Physician Certification Statements (PCS) forms and when and how to use the Advance Beneficiary Notice (ABN).