Cardiac Arrest: Documentation Tips for Practices

Cardiology medical transcription services are becoming increasingly popular as they assist doctors in efficiently managing and caring for their patients. Medical personnel can provide better care and raise medical standards by having accurate medical reports. Similarly, to capture and track cardiopulmonary resuscitation event and outcome characteristics, accurate cardiac arrest documentation is crucial. Clarity in identifying and communicating crucial information for further care is also helpful. In-hospital cardiac arrest resuscitation data collection is beneficial for patients’ interests, as well as for legal, quality control, and scientific reasons.

Significance of Cardiac Arrest Documentation

Cardiac arrest is one of the most critical events in a healthcare context, requiring prompt, coordinated, and standardized actions in order to produce a favorable outcome. Given that healthcare professionals are responsible for determining a patient’s state for resuscitation, it may be presumed that the majority of cardiac arrest calls are due to unplanned or undesirable complications of the illness or medical care being provided, that may sometime fail to treat the cardiac arrest.

In these situations, irrespective of a primary medical duty to audit results and processes, scrutiny of procedure can be anticipated under critical event analysis, complaints, legal proceedings, or, even police or health and safety executive investigations. In these situations, accurate cardiac arrest documentation is essential. If the patient survives, thorough documenting of earlier occasions, timeframes, and procedures is essential for improving or organizing subsequent care.

4 Essential Cardiac Arrest Documentation Tips

Patients who are in cardiac arrest pose some of the most difficult patient care circumstances. The following pointers for improving cardiac arrest patient documentation came from Steve Krantz, a paramedic with 35 years of experience working as a medic and EMS educator in Wisconsin. All of the CPR patient documentation for Krantz’s service underwent quality assurance. So, here are the four tips.

• Any interventions made by onlookers before EMS arrives should be documented: Find out whether and when the bystanders started CPR. Likewise, try to figure out whether the bystanders merely performed compressions or if they also administered rescue breaths. Understanding bystander engagement can help in directing public education campaigns and explaining why interventions like defibrillation may or may not have been successful.
• Verify the patient’s status as it was last heard or seen: Find out whether the patient’s spouse checked straight away or waited until she was done with what she was doing before discovering the patient in cardiac arrest if she claims to have heard a thump in the other room.
• Obtain the patient’s medical history information: This is crucial for patients who are being transferred or for whom field resuscitation is under consideration. Diabetes, kidney illness, cancer, or another medical condition could have made resuscitation more difficult or led to the arrest.
• Capture of the field’s end time: Record the time the last compression was performed if the local procedure permits ending resuscitation efforts. The time at which resuscitation efforts were actually completed was probably far earlier than when the health professionals left the scene.

Maintain accurate, legible records that clearly reflect the essential clinical findings, decisions taken, information provided to patients, and any prescription medicines or other investigations or treatments that were carried out. Record-keeping must be done either simultaneously with the recording of occurrences or as soon as possible afterwards. This is when a cardiology transcription service may prove highly supportive. To meet their transcription needs, cardiologists require excellent accuracy, quick turnaround, and a dynamic workforce.

Cardiologists can dictate while concentrating on giving the patient the best care with the flexible dictation systems and delivery options of medical data available. With the use of smartphone apps, digital recorders, and toll-free phone dictation, dictating medical notes has become rapid and simple. Oral notes can then be typed, checked for inaccuracies, and swiftly converted into transcripts or medical records. Using medical transcription eliminates the need to understand handwritten notes or look for misplaced documents. For health care providers like cardiologists, nurses, and others, having extra time to spend with patients is undoubtedly beneficial.

Doctors can enhance the standard of patient care by outsourcing their medical transcription needs in cardiology. Medical organizations can lighten their effort and concentrate more on patients by not having to worry about recording activities or entering data. Also, by just providing a voice recording, clinicians can have access to accurate medical documentation. Medical staff might not be able to provide the necessary clarity and accuracy in documentation due to the busy schedule at the hospital. They might make mistakes when deciphering words, which would result in inaccurate documentation whereas qualified experts of medical transcription services for cardiology guarantee accuracy in every file they transcribe, and prepare reliable cardiac arrest documentation. They follow HIPAA regulations, which ensures that medical practitioners are not exposed to any legal risk.