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Documentation Silver Cross EMS System Third Trimester November 2011 CME By SCEMSS Staff.

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Presentation on theme: "Documentation Silver Cross EMS System Third Trimester November 2011 CME By SCEMSS Staff."— Presentation transcript:

1 Documentation Silver Cross EMS System Third Trimester November 2011 CME By SCEMSS Staff

2 The plan today…  Talk about documentation  Talk about the drug o’ the month  Talk about the EKG strip o’ the month  Introduce a new feature: EMT-B corner! Since B’s have so many new treatments and skills in their toolbox now, we will review them in more detail in the coming months.

3 Written Communication  An important aspect of EMS communications.  A prehospital care report (PCR) is a written record of an EMS response.

4 A PCR is a legal document, admissible in court.

5 Importance of Documentation  Provides for the following: A written record of the incident A legal record of the incident Professionalism Medical audit Quality improvement Billing and administration Data collection

6 “The content and completeness of the pre-hospital care report directly affects the lawyer’s impression of the incident and influences his decision of whether or not to file a lawsuit.” Richard A. Lazar (Lawyer and public safety risk management expert)

7 Written Record of Incident  May be the only source of information for persons subsequently interested in the event  Record of the incident from beginning to end  Provides a source of identifying pertinent reportable clinical data from each patient reaction

8 Uses for PCRs  Medical  Administrative  Research  Legal

9 Run data in a PCR helps agencies to improve patient care.

10 Some agencies use check boxes, some use bubble sheets, and others use electronic documentation. Silver Cross EMSS STRONGLY recommends that all agencies use some form of electronic PCR.

11 Paper reports - Complete both the narrative and check-box sections of every PCR.

12 ePCR’s – Complete the narrative and any required check boxes or drop-down lists.

13 General Considerations  The Prehospital Care Report should be carefully detailed and legible.  It is viewed as a legal document and is part of the patient’s medical record.  Use of slang terminology or medical abbreviations that are not universally accepted should be avoided.  If you do not know how to spell a word, look it up or use another word.

14 Times  Whenever possible, record all times of treatments and assessments from the same clock.  It is tempting to make up times, but that’s the kind of thing that will catch you up in court.

15 Communications  Communications with the hospital are another important item to document.  Document ANY medical advice or orders you receive and the results of implementing that advice and those orders.  If there were no orders, document “no orders”.

16 Pertinent Negatives  Document all findings of your assessment, even those that are normal. Example: pertinant negatives in a chest pain patient may include “denies difficulty breathing, denies dizziness/weakness, denies d/n/v, denies prior history of chest pain.”

17 Response to treatments  Any time something is done to the patient, their response should be documented.  For example: Following nitro administration, pt reported 4/10 pain After oxygen given, pt reported reduced anxiety. BP increased to 100/60 following bolus.

18 Oral Statements  Whenever possible, quote the patient—or other source of information—directly. Example: Bystanders state the patient was “acting bizarre and threatening to jump in front of the next passing car.”

19 Elements of Good Documentation  Accuracy  Legibility  Timeliness  Unaltered  Professionalism  Completeness

20 Professionalism  Never include slang, biased statements, or irrelevant opinions. “Patient was acting crazy.” “Crew determined patient was obviously anxious.” “It was apparent patient was faking seizure.”

21 Professionalism  There are ways to say these things without saying them.  “Police on scene state pt has prev. psych hx.”  “Pt reports hx of panic attacks, states fingers and toes are numb, states she cannot breath although speaking in complete sentences.”  “During seizure activity pt was responsive to verbal and appeared to avoid EMS intervention.”

22 Narrative Writing  Subjective: part of your narrative comprises any information you elicit during your patient’s history.  Objective: part of your narrative usually includes your general impression and any data you derive through inspection, palpation, auscultation, percussion, and diagnostic testing.

23 Narrative (1 of 2)  Narrative portion of the PCR allows for chronological description of call.  Don’t assume that the electronic drop-down lists cover everything. Two-line narratives ending in “see above for details” or “per below” are unacceptable. It’s better to say in your own words than to just leave it to the computer. In court, your narrative is what counts.

24 Narrative (2 of 2)  The PCR is a legal document and part of the patient’s medical record.  Use of slang or medical abbreviations that are not universally accepted should be avoided. Is TX transport or treatment? Is CO “complains of” or carbon monoxide? Is CP chest pain or cerebral palsy?

25 Two Main Narrative Formats  CHART Chief complaint History Assessment Rx (treatment) Transport  SOAP Subjective Objective Assessment Plan These days SOAP is preferred, although really we don’t care what you use as long as it’s complete and thorough.

26 SOAP Format  S = Subjective  O = Objective  A = Assessment  P = Plan

27 Subjective  What the patient TELLS you! – family, friends, bystanders –use their words in quotes or paraphrased  Age, gender  Chief complaint, History of Illness  Allergies, PMH, med list  Pertinent negatives

28 Objective  What you See, Hear, Touch, Smell!  Paint picture from beginning to end.  Document assessment  Vitals, Glasgow/Trauma Score, EKG  Scene information (MVA, etc)

29 Assessment  S + O = A  Look at the whole picture: What your impression or conclusion is.  Example: Difficulty breathing unknown cause Chest pain, possible MI Right leg pain due to stick impalement.

30 Plan  Step by step synopsis of what you did and how the patient responded Primary assessment Oxygen applied, Pox 84% Needle decompression, left Secondary assessment Pox 93%, report called, no ? or comments Care turned over to ED RN

31 Documentation Revisions  When: as soon as the need for revision is identified.  Date and time of revision must be documented.  Always made by the original author of the document being revised.

32 The Proper Way to Correct an electronic PCR  All of the programs in use in Silver Cross EMSS have an addendum function.  Hand-written changes in an electronic PCR must be reflected in all copies. Usually not do-able.

33 The Proper Way to Correct a Written Prehospital Care Report

34 Special Considerations  Patient refusals  Services not needed  Leaving the ED before finishing your PCR  Psychiatric patients

35 Patient Refusals  Patients retain the right to refuse treatment or transportation if they are competent to make that decision.  Two main types of refusals: Person who is not seriously injured and does not want to go to the hospital. The patient refuses even though you feel he needs it.

36 A patient’s refusal of care requires careful documentation.

37 Services Not Needed  You don’t need to complete a PCR for every invalid assist or well-being check.  However if you perform an assessment and/or care, you must fill out the appropriate documenation.  Patient refusals make up more than half of all court cases!

38 Consequences of Inappropriate Documentation (1 of 2)  Inappropriate documentation has both medical and legal consequences. Do not guess about patient’s problems. Write neatly, clearly, and legibly. Complete your form thoroughly. Spelling counts!

39 Consequences of Inappropriate Documentation (2 of 2)  The primary caregiver is responsible for charting the run report (usually the medic or EMT in the back of the box).  Prior to your agency releasing subpoenaed information, an attorney should determine if a supplemental report needs to be created.

40 So what happens if….  ….you get a call before you have finished your PCR at the hospital?  The PCR is part of the patient record.  You must return to ED ASAP to complete it. By law, a PCR must physically be left by crews in the ED. Some programs allow you to fax from the road. But if you blindly fax, you have no idea if it ever made it to its destination.  New fax machine in medic room at SCH will allow you to quickly print out from your laptop computers.

41 Documenting Psychiatric Patients Adult psychiatric patients who are…  Alert  Oriented,  Answer questions appropriately  And are no danger to themselves or others …have the right to refuse care. Must sign refusal like anyone else, mental status must be completely documented on PCR.

42 When Do They Have to Go Whether They Want to Or Not? Patients who:  display an inability to make a rational judgment  pose a threat to themselves or others Your documentation of this transport against their will is crucial to any court proceedings that may come later.

43 If they are going….  If they agree to go, you fill out the PCR as normal. Detail their willingness, including witnesses, so they can’t claim later they were “forced”.  If they don’t agree to go, this is when we utilize psychiatric petitions.

44 What’s a Petition  A petition is a paper form. States someone feels someone else is danger to self or others States the signer feels the patient requires involuntary psychiatric treatment.  A petition does not “commit” someone. Just allows ER docs to move on to next step Next step: seeking certificate for involuntary admission to psych facility.

45 And then….  If a judge does not approve the certificate from the ER doc, nothing happens.  The petition signed by you only gets the process rolling… it’s not the end of the process.

46 Who Can Fill Out a Petition?  Whomever witnesses dangerous or suicidal behavior can fill out petition. Family members Bystanders Police Us

47 Why us?  Sometimes lay people are reluctant to sign petitions Don’t want to feel like they are responsible for “committing” someone.  Sometimes police don’t want to fill out petitions They may not understand the process or been incorrectly told it’s our problem.  So: if paramedics are the only witnesses to the behavior willing to fill out a petition, then they should do so… For the sake of their patient.

48 On the Other Hand….  If you personally haven’t heard dangerous statements or witnessed the behavior, don’t sign.  RN’s, docs, nursing home staff, police or others who tell you to sign when you have not personally heard statements or witnessed behavior are incorrect.

49 Documentation of Petitions  Petition paperwork includes space for narrative But you must also thoroughly document the petition process in your PCR. Include scene details, patient condition, reluctance by patient, police or witnesses.

50 General Tips for Documentation  Take notes, chart ASAP  Clear, concise, legible, leave no blank spaces  Approved abbreviations/symbols  Black ink, no whiteout or erasing  Military time  Response to interventions  Sign with full name & title immediately after last sentence  C.Y.A.: Not charted means NOT DONE!!!

51 Silver Cross EMSS Drug O’ the Month Glucose/Dextrose

52 Oral Glucose  A gel mix of dextrose (sugar) and water.  Used to raise low blood sugar.  Self-administered or given by EMS.  Only patients with intact gag reflex (awake)  Taste compares to super-sweet frosting.  Patient can swallow or allow gel to stay in mouth momentarily.  Glucose molecules will absorb directly though oral tissue or the small intestine.

53 Dextrose 50%  Also known as D 50 W  For hypoglycemia, hyperkalemia, AMS without known cause, seizures  Given IVP. Bigger catheter is better.  Thick and hard to push through smaller catheters. Dextrose can sclerose veins and lead to tissue necrosis.  No hand IV’s. No positional IV’s.

54 EMT-B Corner The Glucometer  You could always give oral glucose for low blood sugar.  Now in the new SMO’s you can also give glucagon intranasally via the MAD device.  So the next obvious skill step: we want you to check blood sugars with glucometers.  Since many B’s are not familiar with that skill, here’s a quick recap.

55 Testing Tips  Of course you should always be wearing gloves.  Choose a finger. Diabetic patients will often tell you which finger they prefer. Wipe finger with alcohol wipe, let dry completely.  Insert a test strip into your meter. Some models like you to put the blood on the strip before testing. Know your model.  Use lancing device on SIDE of fingertip to get drop of blood. Closer to the nail the better… people need the pads of their fingers to do stuff! Or use whatever method you prefer to get the blood from an IV catheter.  You may have to squeeze or massage the finger to get enough blood out. But too much squeezing/massaging can change the character of the blood. Hold hand downward to allow gravity to help.

56 Dexi tips continued  Touch and hold the edge of the test strip to the drop of blood, and wait for the result.  Blood glucose level will appear on the meter's display. Many models read “hi” or “low” when sugar is below 20 or above 600. Know your meter.  Some newer meters out there let you use forearm, thigh or fleshy part of hand.  It’s OK to use the patient’s meter in a pinch, or let him/her do it, but always check with yours as well. Patient’s glucometer may not have been calibrated lately. Plus a lot of patients are not too good at finger hygiene… eww!

57 ALS Strip O’ the Month Sinus Bradycardia

58 Sinus Bradycardia  If the SA node fires slower than normal for the patient’s age, the rhythm is called sinus bradycardia In adults and teens, sinus bradycardia is a heart rate of less than 60 bpm

59 Sinus Bradycardia — How Do I Recognize It? RateLess than 60 bpm RhythmP-P interval regular, R-R interval regular P wavesPositive (upright) in lead II, one precedes each QRS complex, P waves look alike

60 Sinus Bradycardia — How Do I Recognize It? PR interval0.12–0.20 second and constant from beat to beat QRS duration0.10 second or less unless an intraventricular conduction delay exists

61 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Sinus Bradycardia — How Do I Recognize It?  Sinus bradycardia at 46 bpm ST-segment depression

62 Sinus Bradycardia — What Causes It?  Occurs in adults and children during sleep  Common in well- conditioned athletes

63 Sinus Bradycardia — What Causes It?  Present in up to 35% of people under 25 years of age while at rest  Common dysrhythmia associated with acute myocardial infarction (MI) Often seen in inferior and posterior infarction

64 Sinus Bradycardia — What Causes It?  Vagal stimulation Coughing Vomiting Straining to have a bowel movement Sudden exposure of the face to cold water Carotid sinus pressure

65 Sinus Bradycardia — What Causes It?  Inferior MI  Posterior MI  Disease of SA node  Vagal stimulation  Hypoxia  Hypothermia  Increased intracranial pressure  Post heart transplant  Hypothyroidism  Hypokalemia  Hyperkalemia  Obstructive sleep apnea  Medications Calcium channel blockers Digitalis Beta-blockers Amiodarone Sotalol

66 Sinus Bradycardia — What Do I Do About It?  Changes in mental status  Low blood pressure  Chest pain  Shortness of breath  Signs of shock  Congestive heart failure  Pulmonary congestion  Fall in urine output  Cold, clammy skin Signs and symptoms of hemodynamic compromise:

67 Sinus Bradycardia — What Do I Do About It?  No treatment if not symptomatic  If symptomatic because of the slow rate, treatment may include: Oxygen IV access Atropine Transcutaneous pacing (TCP)

68 References  Paramedic Practice Today: Above and Beyond, Barbara Aehlert.— Elsevier, 1 st ed.  Mosby’s Paramedic Textbook, Mick Sanders. – Elsevier, revised 3 rd ed.  ECG’s Made Easy, Barbara Aehlert. – Elsevier, 4 th ed.  SCEMSS staff  Any questions? Feel free to call us at or Thank you!


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