Presentation on theme: "Pre-Hospital Patient Care Reports"— Presentation transcript:
1 Pre-Hospital Patient Care Reports DOCUMENTATIONPre-Hospital Patient Care ReportsPre-hospital patient care report abbreviated as PPCRJack Boyce, EMT-PGates County Rescue & EMSPasquotank-Camden County EMS
2 PURPOSES Preserves basic patient information Records changes in patient conditionJustifies treatmentAllows continuity of careSatisfies regulatory requirements
3 PROVIDESProtection for EMS personnelReflection of good patient care
4 Your Documentation Reflects Your PROFESSIONALISM If your report is sloppy others may assume your care and treatment were sloppy
6 Medical UsesDetermine patient condition before arrival to hospital (mechanism of injury/nature of illness)Chronological account of patient statusBaseline for comparing assessment findings and detecting trends of improvement or deterioration
7 This is part of the patients medical record, a copy of your report MUST be left at the receiving facility
8 Administrative UsesGain information for quality improvement (detect a single providers weaknesses or EMS system weaknesses that could be improved upon)System assessment (response times, call locations, use of lights and sirens)Billing for reimbursement of services providedSingle provider weaknesses can range from how someone implements protocols, to how they perform procedures, to knowledge base information. EMS system weaknesses can range from when and how to implement incident command, to response times, to when and how to use lights and sirens, to number of units responding, to what should be paged out for certain incidents.
9 Research UsesTo determine effectiveness of medical devices, drugs, and invasive proceduresAED/Defibrillator, new drugs on market, whether or not certain therapy is helpful when implemented early in treatment
10 Legal Uses Permanent part of patients medical record May be your SOLE source of information in courtMay be your BEST and ONLY defense in court
11 ALWAYS write your documentation as if you knew you would have to refer to it someday in court
12 SHOULD BEAccurateCompleteLegibleFree of extraneous information
13 Should be written by the provider performing patient care ALS personnel should remember that the highest certified technician is in charge of not only their actions but the actions of other crew members too
14 Accuracy Document FACTS only Do NOT speculate about patient or incidentAvoid reporting a diagnosis but instead note primary/secondary impressions(EMS does not diagnose, DOCTORS diagnose)Record observations, assessments, treatments/interventions, effects of treatments/interventions, re-assessmentsSpeculation on patient being drunk or overdosed or crazy. Diagnostic impressions such as massive heart attack, hemorrhagic stroke, aortic aneurism, appendicitis, urinary tract infection, etc.
15 Describe the patients condition on arrival of scene, during care, before and after interventions, and upon arrival to hospital
16 Completeness Include all requested information Failure to document implies failure to considerIf you look for something and it isn’t there, include its absenceIf it ISN’T documented it DIDN’T happen or WASN’T doneRequested info such as Name, DOB, SSN, Address, etc. If they are complaining of abdominal pain and you don’t document that you assessed the abdomen then you failed to consider the patients complaint. If you look for a pulse and it is absent, document it.
17 Document exactly WHAT you did, WHEN you did it, and the EFFECTS of your interventions
18 CompletenessDocument all findings of your assessment, even those that are normal (Pertinent Negatives)Demonstrates thoroughness of examinationHelps rule out problemsEX: if a patient is having difficulty breathing and has clear lung sounds with no edema you can rule out congestive heart failure
19 CompletenessIf you contact medical control for orders or advice DOCUMENT IT
20 LegibilityClear, legible documentation makes it difficult for other people to tamper with or misinterpretWhen you have forgotten about an event and need to reference your documentation, if it is not legible events may remain unclear or misinterpretedRemember that you are not the only person reading your report, other medical staff review your information to assist in quality improvement, research, legal and medical issuesA sloppy report = sloppy care
21 LegibilityIf you use abbreviations make sure there meanings are clear and standardizedEX: “CP” – chest pain, cardiac perfusion, cerebral palsyEX: “CO” – cardiac output, carbon monoxideEX: “BLS” – basic life support, burns/lacerations/swelling
22 Legibility When correcting mistakes, do it properly Draw a single line through the error, write the correct information beside it and initial the change
23 Extraneous Information AVOID labeling patientsIf comments made by the patient need to be included in your documentation preface them with “Per the patient…” or “Patient stated…”AVOID humor, the public and the courts DO NOT regard EMS as a funny businessAvoid labeling the patient as a crack addict or an alcoholic, it may just be a bad day for them.
24 LIBEL – writing false or malicious words intended to damage a persons character You can be charged with this in court
25 NARRATIVE SECTIONFrom a patient care and legal point of view this is the MOST IMPORTANT part of the run report.
26 NARRATIVE SECTIONYour narrative should paint a picture of the scene, events leading up to the call, what you found in your assessment, care provided, & how transferred to the hospital
27 Methods of Documentation CHARTSOAPCHRONOLOGICAL
28 CHART C = chief complaint H = history A = assessment R = treatment T = transport
29 CHART C = chief complaint Chief complaint is what the patient is complaining of exactly as the patient statesEX: C – pt states my chest hurts
30 History of present illness CHARTH = historyUnder history you should include:History of present illnessPast historyCurrent health status
31 CHART A = assessment Under assessment you should include: Vital signs General impressionPhysical examDiagnostic tests
32 CHART R = treatment Under treatment you should include: Standing orders (Protocols)Physician orders (Medical Direction)(All treatments and interventions)
33 Effects of interventions CHARTT = transportUnder transport you should include:Effects of interventionsMode of transportOngoing assessments
34 SOAPS = subjectiveO = objectiveA = assessmentP = plan
35 History of present illness SOAPS = subjectiveUnder subjective you should include:Chief complaintHistory of present illnessPast historyCurrent health statusFamily history
36 SOAP O = objective Under objective you should include: Vital signs General impressionPhysical ExamDiagnostic tests
37 What you believe your patients problem is SOAPA = assessmentUnder assessment you should include:Field diagnosisWhat you believe your patients problem is
38 SOAP P = plan Under plan you should include: Standing orders (Protocols)Physician orders (Medical Direction)Effects of interventionsMode of transportOngoing assessment
39 CHRONOLOGICALStart documenting from the time you were dispatched, hitting high points and key events during call to include scene findings, patient assessment findings, interventions and outcomes. Narrative ends when you reach the point that the call is cleared.Can be used in conjunction with actual event times or without by simply keeping events in order from beginning to end.Ex: 1200 – arrived scene to find patient lying on ground responsive to painful stimuli, c-spine taken1201 – airway assessed, patent and maintained by patient, patient breathing and has a pulse, rapid blood sweep done finding no major life threatening bleeds, pt was backboarded, c- collar applied, CID in place, pt placed on 15 LPM O2 NRB1215 – initial set of vitals taken, etc…
40 Patient RefusalsPatients retain the RIGHT to REFUSE treatment or transport IF they are COMPETENT to make that decision
41 Reliable PatientsCALMCOOPERATIVESOBERALERTWITHOUT OTHER INJURIES
42 Unreliable Patients MAY Have: Head/Brain injuriesAltered Level of ConsciousnessIntoxicationOther distracting injuries
43 AMA = AGAINST Medical Advice Patient refuses care even though you feel they need it
44 Patient Refusals Documentation checklist: Thorough patient assessment Competency of patientYour recommendations for the need of care and transportExplanation of possible consequences INCLUDING DEATHPatients understanding of explanations
45 If there are any doubts in your mind about letting a patient sign a refusal CONTACT MEDICAL DIRECTION FOR ADVICE
46 Things to IncludeImportant observations – suicide notes, weapons, hostile family or bystandersPatients refusal to have an area of their body assessed or difficulty to adequately assess an areaDevices used – backboards, scoop stretchers, splints, stair-chair, etc.
47 MVC’S Type of collision Degree of damage Location of patient Use of restraint or safety devices
48 FALLS How far did the patient fall? What type of surface did the patient fall on?What caused the patient to fall?
49 HEAD INJURIES Level of consciousness Pupillary response Discharge from nose or earsBattle signsRaccoon eyesCervical pain, tenderness, deformityParalysisAltered motor functionAltered sensory function
50 CHEST TRAUMA Position of trachea Lung sounds JVD Paradoxical chest movement or flail chestBruisingCrepitus or pain with palpation
51 Extremity Trauma Color and Temp. Pulse, movement, sensation (PMS) Any DCAPBTLS
52 Knife WoundsLength and type of bladeApprox size of wound made
53 Gunshots (GSW) Type of gun Caliber of gun, if known Distance victim from shooterEntry and exit wounds
54 Patient RestraintBe VERY specific of why you restrained the patient: behavior that you felt constituted a threat to patient or anyone else’s safetyWho restrained the patientWhat kind of restraints were usedNew injuries patient complains of during and after restraintAreas of body restrained
55 PaperlessMany services throughout the country have started using electronic run reporting methods.The state of North Carolina requires all EMS agencies to report data to the state PreMis system.Though resistance is initially high, people quickly become dependent on the latest in patient care reporting technology.
56 SummaryComplete, accurate, legible documentation is an important key to– Providing continuity of patient care andrecording the event– Protection from litigation– Credibility as health care professionals– Financial reimbursement
58 Quick Quiz What are the 4 ways documentation is used in EMS? Since your PCR is part of the patient’s medical record, a copy should be left where?Always write your documentation as if you knew you would have to refer to it someday in _______?______ is writing false or malicious words intended to damage a persons character?Normal assessment findings are called _____ _____?From a patient care and legal point of view this is the most important part of the run report?Patients retain the right to refuse treatment or transport if they are ______ to make that decision?Of the 3 narrative methods listed, which one do you prefer?
59 Narrative EvaluationYou respond to a 55 year old male complaining of chest painMake up a history for this patient, an assessment, and interventions/treatmentsCreate a narrative to document this call
60 Continuing Education Credit Complete the 8 quiz questions and a practice narrative after reviewing this PowerPoint.Include the quiz answers & narrative in a document and to your instructor atYou will receive 3 hours of con-ed credit after successful completion.
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