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DOCUMENTATION Pre-Hospital Patient Care Reports Jack Boyce, EMT-P Gates County Rescue & EMS Pasquotank-Camden County EMS.

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Presentation on theme: "DOCUMENTATION Pre-Hospital Patient Care Reports Jack Boyce, EMT-P Gates County Rescue & EMS Pasquotank-Camden County EMS."— Presentation transcript:

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2 DOCUMENTATION Pre-Hospital Patient Care Reports Jack Boyce, EMT-P Gates County Rescue & EMS Pasquotank-Camden County EMS

3 PURPOSES Preserves basic patient information Records changes in patient condition Justifies treatment Allows continuity of care Satisfies regulatory requirements

4 PROVIDES Protection for EMS personnel Reflection of good patient care

5 Your Documentation Reflects Your PROFESSIONALISM

6 USES Medical Administrative Research Legal

7 Medical Uses Determine patient condition before arrival to hospital (mechanism of injury/nature of illness) Chronological account of patient status Baseline for comparing assessment findings and detecting trends of improvement or deterioration

8 This is part of the patients medical record, a copy of your report MUST be left at the receiving facility

9 Administrative Uses Gain 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 provided

10 Research Uses To determine effectiveness of medical devices, drugs, and invasive procedures

11 Legal Uses Permanent part of patients medical record May be your SOLE source of information in court May be your BEST and ONLY defense in court

12 ALWAYS write your documentation as if you knew you would have to refer to it someday in court

13 SHOULD BE Accurate Complete Legible Free of extraneous information

14 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

15 Accuracy Document FACTS only Do NOT speculate about patient or incident Avoid 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-assessments

16 Describe the patients condition on arrival of scene, during care, before and after interventions, and upon arrival to hospital

17 Completeness Include all requested information Failure to document implies failure to consider If you look for something and it isn’t there, include its absence If it ISN’T documented it DIDN’T happen or WASN’T done

18 Document exactly WHAT you did, WHEN you did it, and the EFFECTS of your interventions

19 Completeness Document all findings of your assessment, even those that are normal (Pertinent Negatives) Demonstrates thoroughness of examination Helps rule out problems EX: if a patient is having difficulty breathing and has clear lung sounds with no edema you can rule out congestive heart failure

20 Completeness If you contact medical control for orders or advice DOCUMENT IT

21 Legibility Clear, legible documentation makes it difficult for other people to tamper with or misinterpret When you have forgotten about an event and need to reference your documentation, if it is not legible events may remain unclear or misinterpreted Remember 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 issues A sloppy report = sloppy care

22 Legibility If you use abbreviations make sure there meanings are clear and standardized EX: “CP” – chest pain, cardiac perfusion, cerebral palsy EX: “CO” – cardiac output, carbon monoxide EX: “BLS” – basic life support, burns/lacerations/swelling

23 Legibility When correcting mistakes, do it properly Draw a single line through the error, write the correct information beside it and initial the change

24 Extraneous Information AVOID labeling patients If 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 business

25 LIBEL – writing false or malicious words intended to damage a persons character

26 NARRATIVE SECTION From a patient care and legal point of view this is the MOST IMPORTANT part of the run report.

27 NARRATIVE SECTION Your 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

28 Methods of Documentation CHART SOAP CHRONOLOGICAL

29 CHART C = chief complaint H = history A = assessment R = treatment T = transport

30 CHART C = chief complaint Chief complaint is what the patient is complaining of exactly as the patient states EX: C – pt states my chest hurts

31 CHART H = history Under history you should include: History of present illness Past history Current health status

32 CHART A = assessment Under assessment you should include: Vital signs General impression Physical exam Diagnostic tests

33 CHART R = treatment Under treatment you should include: Standing orders (Protocols) Physician orders (Medical Direction) (All treatments and interventions)

34 CHART T = transport Under transport you should include: Effects of interventions Mode of transport Ongoing assessments

35 SOAP S = subjective O = objective A = assessment P = plan

36 SOAP S = subjective Under subjective you should include: Chief complaint History of present illness Past history Current health status Family history

37 SOAP O = objective Under objective you should include: Vital signs General impression Physical Exam Diagnostic tests

38 SOAP A = assessment Under assessment you should include: Field diagnosis What you believe your patients problem is

39 SOAP P = plan Under plan you should include: Standing orders (Protocols) Physician orders (Medical Direction) Effects of interventions Mode of transport Ongoing assessment

40 CHRONOLOGICAL Start 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 taken 1201 – 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 NRB 1215 – initial set of vitals taken, etc…

41 Patient Refusals Patients retain the RIGHT to REFUSE treatment or transport IF they are COMPETENT to make that decision

42 Reliable Patients CALM COOPERATIVE SOBER ALERT WITHOUT OTHER INJURIES

43 Unreliable Patients MAY Have: Head/Brain injuries Altered Level of Consciousness Intoxication Other distracting injuries

44 AMA = AGAINST Medical Advice Patient refuses care even though you feel they need it

45 Patient Refusals Documentation checklist: Thorough patient assessment Competency of patient Your recommendations for the need of care and transport Explanation of possible consequences INCLUDING DEATH Patients understanding of explanations

46 If there are any doubts in your mind about letting a patient sign a refusal CONTACT MEDICAL DIRECTION FOR ADVICE

47 Things to Include Important observations – suicide notes, weapons, hostile family or bystanders Patients refusal to have an area of their body assessed or difficulty to adequately assess an area Devices used – backboards, scoop stretchers, splints, stair-chair, etc.

48 MVC’S Type of collision Degree of damage Location of patient Use of restraint or safety devices

49 FALLS How far did the patient fall? What type of surface did the patient fall on? What caused the patient to fall?

50 HEAD INJURIES Level of consciousness Pupillary response Discharge from nose or ears Battle signs Raccoon eyes Cervical pain, tenderness, deformity Paralysis Altered motor function Altered sensory function

51 CHEST TRAUMA Position of trachea Lung sounds JVD Paradoxical chest movement or flail chest Bruising Crepitus or pain with palpation

52 Extremity Trauma Color and Temp. Pulse, movement, sensation (PMS) Any DCAPBTLS

53 Knife Wounds Length and type of blade Approx size of wound made

54 Gunshots (GSW) Type of gun Caliber of gun, if known Distance victim from shooter Entry and exit wounds

55 Patient Restraint Be VERY specific of why you restrained the patient: behavior that you felt constituted a threat to patient or anyone else’s safety Who restrained the patient What kind of restraints were used New injuries patient complains of during and after restraint Areas of body restrained

56 Paperless Many 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.

57 Summary Complete, accurate, legible documentation is an important key to – Providing continuity of patient care and recording the event – Protection from litigation – Credibility as health care professionals – Financial reimbursement

58 ANY QUESTIONS OR THOUGHTS?

59 Quick Quiz 1. What are the 4 ways documentation is used in EMS? 2. Since your PCR is part of the patient’s medical record, a copy should be left where? 3. Always write your documentation as if you knew you would have to refer to it someday in _______? 4. ______ is writing false or malicious words intended to damage a persons character? 5. Normal assessment findings are called _____ _____? 6. From a patient care and legal point of view this is the most important part of the run report? 7. Patients retain the right to refuse treatment or transport if they are ______ to make that decision? 8. Of the 3 narrative methods listed, which one do you prefer?

60 Narrative Evaluation You respond to a 55 year old male complaining of chest pain Make up a history for this patient, an assessment, and interventions/treatments Create a narrative to document this call

61 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 at You will receive 3 hours of con-ed credit after successful completion.


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