Saturday, February 18, 2012

What legislation requires all first aid treatment to be recorded?

How long do records need to be keptWhat legislation requires all first aid treatment to be recorded?This type of Legislation is generally State or local. In most areas, there isn't any such legislation that specifically requires ALL "first aid" to be recorded. Usually, any such requirement is targeted to specific health care entities, such as Hospitals and EMS (emergency medical services / 911), and sometimes even then, only certain interventions are recorded (giving someone a band aid for a hang-nail doesn't usually require documentation).

The most common misconception is EMS is the medical record being a "legal document". In reality, it is not. A "Lea; document" has specific legal definitions, such as a document signed by a judge or court clerk. While it can certainly be used in court, it is used in a similar way as any piece of evidence. This is why much of the requirement for documentation rests with the policies of that particular service providing the care.

An individual for example (in most states, with "good sam laws" varying widely) has no such requirement, though the care they provide will likely be recorded by EMS if they take over care.

Good luck with your research, if you find anything I haven't, please post it, I'd love to read it.

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