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 Requirements  Musts/Omissions  Documentation  Subjective v. Objective  Assessments  Comments  Redundancy  Acceptable / Authorized Medical Abbreviations.

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Presentation on theme: " Requirements  Musts/Omissions  Documentation  Subjective v. Objective  Assessments  Comments  Redundancy  Acceptable / Authorized Medical Abbreviations."— Presentation transcript:

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2  Requirements  Musts/Omissions  Documentation  Subjective v. Objective  Assessments  Comments  Redundancy  Acceptable / Authorized Medical Abbreviations  GCS  RMA’s / Forms  Rear of PCR  Telling a Story

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5 ◦ Pre-hospital ◦ Pre-hospital – These are issues and conditions the ED staff can’t see and don’t know about. Important to document.  Accidents – condition of car, position of patient  Homes – condition, temperature, medical devices  Nursing facilities – need I say more

6 ◦ Care ◦ Care – Simple…What treatment did you provide to the patient  Again, if it’s not visible, the ED staff won’t know what you did  Self treatment prior to EMS arrival

7 ◦ Report – ◦ Report – As by it’s very definition:  (noun)  a usually detailed account or statement  (transitive verb)  To relate the words or sense of  To make a written record or summary of  To give a formal or official account or statement of

8 ◦ Report  Examples  Book reports  Accident reports  Report cards  Reporters

9 ◦ Report ◦ TELL A STORY ◦ RELAY INFORMATION

10 Date (mm/dd/yr) 07/18/ Can be completed post call

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12  Agency Name – BSBRA  Dispatch Information ◦ Plain English – Chest Pain ◦ EMD Code – 10D3  Call Location ◦ As specific as possible ◦ Address ◦ “IFO”, “in vicinity of”, intersection, direction, business name, etc.  Location Code – 5154 (Islip Township) ◦ 5100 only if unsure

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14  Times ◦ Must be filled in prior to leaving the hospital ◦ Call headquarters or MedCom if needed ◦ Must correlate with vital signs

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17  Name – Spell correctly ◦ This is what is used at triage to get pt. into the system  Phone – NOT ◦ should be an emergency contact, NOT the patient’s personal cell  DOB/Age – Again, be accurate ◦ If you can’t do the math and figure out the person’s age, ASK THEM  SSN – Important for patient tracking

18 - Jose Diaz - Juan Martinez - Victor Rivera - Julio Gonzalez - Maria Sanchez  Michael Brown  Susan Smith  Tom Robinson  Frank Williams  Karen Jones

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20  Physician ◦ General Practitioner if possible ◦ Can write in specialists too  Care in Progress on Arrival ◦ Self explanatory ◦ If possible, name and vehicle  Mechanism of Injury Fill in and  Extrication required document  Seat belt used accordingly

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22  Use the words of the patient ◦ “I fell and hurt my knee” ◦ “I thought I was going to pass out”  Use the words of a witness ◦ “He fell down and hit his head” ◦ “She started shaking a lot”  Do NOT write diagnosis here ◦ “Syncope”, “blunt trauma”, “diabetic”  If patient cannot or doesn’t make a statement: ◦ None – pt unresponsive – pt AMS

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24  Presenting problem ◦ Fill in circle of ALL that apply  Cardiac related, Respiratory Distress, Pain, Other  Head injury, Fracture, Bleeding ◦ Circle primary condition/incident ◦ Pain and Other – be specific  L sided c/p radiating to jaw and L arm  Nausea, dizziness, AMS

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26  Fill in circle of all that apply  Other: GERD, Vertigo, Gout, Anxiety, etc  Allergies and Medications ◦ WRITE SMALL ◦ DO NOT write up the side of the PCR ◦ DO NOT use up entire assessment/comment section if the pt. eats the pharmacy daily ◦ Use continuation form ◦ “See list” - unacceptable

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28  Times MUST correlate with response times!!!!!  Respirations and Pulse ◦ Rate and condition  Blood Pressure ◦ “Palp” or “P” is acceptable – document!  LOC ◦ How does the pt. respond based on stimuli ◦ Alert does not mean oriented

29 ◦ 1 st set of v/s should be within 1 st five minutes of patient contact – if not, document reason for delay  Prolonged extrication, delayed pt. contact, pt. agitation, etc. ◦ Make every effort to obtain 2 sets of v/s, especially if giving treatment – if only one set, document why

30 ◦ GCS – Glasgow Coma Scale

31 ◦ Eye Opening (1-4)  Similar to LOC, but different

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33 ◦ Verbal Response (1-5)  Oriented  Confused  Inappropriate Words  Incomprehensible Sounds  None

34 ◦ Motor Response (1-6)  Obeys Command  Localizes Pain  Withdraw (pain)  Flexion (pain)  Extension (pain)  None

35  Glasgow Coma Scale ◦ For any sum other than 15 or 3, write the individual numbers of each assessment above the total ◦ Eye opening – spontaneous (4) ◦ Verbal Response – confused (4) ◦ Motor Response – obeys command (6) ◦ Total = 14

36  Pupils ◦ Difference between R & L?? ◦ It’s okay if not assessed – document  Skin ◦ Unremarkable means exactly that  CUPS ◦ Critical ◦ Unstable ◦ Potentially Unstable ◦ Stable

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38  Treatment Given ◦ Fill in circle to all that apply ◦ Fill in all boxes and blank lines ◦ “Other” section– PFA / ES not necessary ◦ Questions regarding specific treatments?

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40  Subjective ◦ Personal perspective ◦ Feelings, beliefs, opinions, attitudes ◦ Existing in the mind ◦ Cannot be seen  Objective ◦ Object ◦ Something tangible ◦ Can be seen/touched ◦ Measurable fact or evidence

41  Subjective ◦ What the pt. tells you ◦ Pain, weakness, dizziness, nausea ◦ Events leading up to incident (onset, duration) ◦ Treatment prior to EMS arrival  Objective ◦ What you observe ◦ Lacerations, deformities, ecchymosis, paradoxical breathing ◦ Knife sticking out of pt. chest ◦ Treatment prior to EMS arrival

42  Begin telling your story  Try to be as chronologically correct as possible  How was pt. found, c/o, onset, duration, severity, associated symptoms, aggravating/alleviating factors  Witness/family statements

43  Continue your story with tangible observations  Physical assessment ◦ Head to toe ◦ Vectored exam ◦ Pertinent (+) and (-) findings ◦ DO NOT use words/terms if you don’t know what they mean!!!! K.I.S.S. ◦ Abbreviations

44  May continue your assessments  Treatment (Rx) ◦ No need for redundancy ◦ Chronological ◦ Effects of treatment  1 st rule of medicine – DO NO HARM ◦ Explain your omissions/justifications ◦ Transport – pt. position, incidents/change in pt. status, hospital choice ◦ Pt. refusal of treatment/txp – RMA ◦ Medical Control

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46  Disposition ◦ See list ◦ Non-Hospital Disposition Codes ◦ Southside Hospital (SSH) ◦ Good Samaritan Hospital (GSH) – 515  Crew ◦ In charge means technician in charge/team leader of the patient ◦ Person completing the PCR ◦ DOES NOT mean highest ranking officer/crew chief on scene  Continuation Form Used - circle

47  Know what you are saying and abbreviating  SPELLING!!  Use approved medical abbreviations

48 LLQ / LLR

49 LLQ – Lower Left Quadrant LLR – Left Lateral Recumbant

50 DKA / AKA

51 DKA – Diabetic KetoAcidosis AKA – Also Known As - Above the Knee Amputation

52 HEENT

53 HEENT – Head, Eyes, Ears, Nose, Throat  HEENT clear???  Document specifically what was checked ◦ Trauma/deformity, pupils, conjunctiva, discharges, swelling/edema, etc

54 PEARL PERRL PERRLA

55 PEARL – Pupils equal and reactive to light PERRL – Pupils equal round reactive to light PERRLA – Pupils equal round reactive to light and accommodation

56 PMS

57  Pulse, motor, sensory ◦ WRONG  Premenstrual Syndrome ◦ 46 y/o male found leaning forward in chair c/o abdominal pain. Pt PMS intact

58 WNL

59  Within Normal Limits ◦ WRONG  We Never Looked ◦ V/S wnl, trauma exam wnl, PMS wnl ◦ Unremarkable is acceptable

60 MALEFEMALE ♂ ♀

61  The less you write the better. ◦ Less likely to make mistakes ◦ Less likely to be questioned

62  100% FALSE!! ◦ If you didn’t write it, you didn’t do it ◦ Court / subpoena

63  Be confident in treating your patient and documenting it  Be able to justify any course of action you take or omit

64  Fill out a PCR for EVERY activation ◦ Transport ◦ Care transfer ◦ Cancellation (even if you don’t roll) ◦ Stand-by

65  Remember to tell a story  We are an extension of the ER ◦ Describe the events leading up to the transfer of care to the ED staff  Be a patient care advocate ◦ Pt. pedigree information ◦ Treatment ◦ Speak up to triage RN / staff

66 Completed PCR’s


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