1. CHAPTER 14 Documentation “If it’s not written down, you didn’t do it!!!”

2. Minimum Data Patient Information Gathered at the time of the EMT–B’s initial contact with patient on arrival at scene, following all interventions, and on arrival at facility

3. Chief complaint/what the patient tells you is wrong/why EMS was called Level of consciousness (AVPU), mental status Systolic BP for patients greater than 3 years old Minimum Data Patient Information Continued…

4. Skin perfusion (capillary refill) for patients less than 6 years old Skin color and temperature Pulse rate/quality Respiratory rate and effort Minimum Data Patient Information

5. Minimum Data Administrative Information Time incident reported Time unit notified Time of arrival at patient Time unit left scene Time of arrival at destination Time of transfer of care

6. Minimum Data Accurate and Synchronous Clocks Always use times that dispatch gives you because there could be a difference of several minutes between your watch or the ambulance clock. You want to make sure that you are being consistent and that your PCR matches the dispatch records.

7. The Prehospital Care Report (PCR)

8. Prehospital Care Report: Functions Continuity of care – a form that is not read immediately in the emergency department may very well be referred to later for important information Legal document – could be called to court A good report has documented what emergency medical care was provided and the status of the patient on arrival at the scene and any changes upon arrival at the receiving facility The person who completed the form ordinarily must go to court with the form Information should include objective and subjective information and be clear; there should be no opinions, and you should write neatly and succinctly

9. Prehospital Care Report: Functions Educational – used to demonstrate proper documentation and how to handle unusual or uncommon cases Administrative Billing information Service Statistics

10. Prehospital Care Report: Functions Research – to improve response times/scheduling/deployment, etc… Evaluation and Continuous Quality Improvement – look at poor/excellent patient care Conformity or Patient Care Standards – calls are routinely reviewed for conformity to current medical and organizational standards

11. Prehospital Care Report (Handwritten) Traditional written form with check boxes and a section for a narrative

12. Prehospital Care Report (Computerized)

13. Pen-Based Computer and PDA Computerized version where information is filled in by a means of an electronic clipboard or a similar device

14. PCR Data Set Each piece of information is an element (i.e. vital signs). U.S. DOT defines minimum elements for a PCR.

15. Data Sections of the PCR

16. Run Data Includes date, times (rely on dispatcher for these), service, unit, names of crew, agency name, location of call

17. Patient Data Patient name, address, date of birth, race, chief complaint (put in quotes), patient’s medications, insurance information/billing, sex, age, nature of call, mechanism of injury, location of patient, treatment administered prior to arrival of EMT-Basic, signs and symptoms, care administered, baseline vital signs, SAMPLE History and changes in condition

18. Check Boxes Efficient method Be sure to fill in box completely/you may be able to write a few words Avoid stray marks

19. Narrative

20. Narrative Describe, don’t conclude; be objective (include presentation, assessment findings, treatment, transport information Include pertinent negatives Record important observations about the scene (i.e. suicide note, weapon, etc…)

21. Narrative Avoid slang and radio codes. Use abbreviations only if they are standard When information of a sensitive nature is documented, note the source of that information (i.e. communicable diseases) State reporting requirements Use correct spelling, especially medical terminology. If you do not know how to spell it, find out or use another word. Also, if explanation can be made clearer with plain English, use it. Make sure you know the meaning of what you are writing because if you do not, it could result in loss of credibility, embarrassment, and have a negative impact on patient care For every reassessment, record time (military) and findings Write legibly.

22. Prehospital Care Report Confidentiality The form itself and the information on the form are considered confidential. Be familiar with your state laws Regulated by Health Insurance Portability Accessibility Act (HIPAA) Must keep completed reports in locked box Distribution of copies Determined by local & state protocol and procedures will determine where the different copies of the form should be distributed A copy will be filed with your agency, a copy will be sent to the state, and a copy will be left with the hospital ER; no other copies should be distributed without written authorization and subpoena

23. Falsification of PCR When an error of omission or commission occurs, the EMT- Basic should not try to cover it up. Instead, document what did or did not happen and what steps were taken (if any) to correct the situation omission – those in which an important part of the assessment or care was left out commission – actions performed on the patient that are wrong or improper Falsification of information on the PCR may lead not only to suspension or revocation of the EMT-Basic’s certification/license, but also to poor patient care because other health care providers have a false impression of which assessment findings were discovered or what treatment was given Continued…

24. Specific areas of difficulty Vital Signs – document only the vital signs that were actually taken (if you didn’t have time, don’t make them up) Treatment – if a treatment like oxygen was overlooked, do not chart that the patient was given oxygen Falsification of PCR

25. Patient Refusal Competent adult patients may legally refuse treatment. Age? Impaired by alcohol/drugs? Mentally competent? Impaired by medical condition?

26. Before the EMT-Basic leaves the scene, however, he should: Try again to persuade the patient to go to a hospital Ensure the patient is able to make an informed, rational decision (i.e. not under the influence of alcohol or other drugs, or illness/injury effects – mental status). Inform the patient why he should go and what may happen if he does not Consult medical direction as directed by local protocol If the patient still refuses, document all assessment findings and emergency medical care given, then have the patient sign a refusal form (also write in narrative section of PCR). Have family member, police officer or bystander sign the form as a witness. If the patient refuses to sign the refusal form, have a family member, police officer or bystander sign the form verifying that the patient refused to sign. Patient Refusal

27. Complete the pre-hospital care report Complete patient assessment Care EMT-Basic wished to provide for the patient. This is a common situation where an EMT may be held liable. State that the EMT-Basic explained to the patient the possible consequences of failure to accept care, including potential death Offer alternative methods of gaining care State willingness to return. Patient Refusal

28. Special Documentation Issues

29. Correction of Errors Errors discovered while the report form is being written (before it is distributed to anyone) Draw a single horizontal line through the error, initial it, and write the correct information beside it. Do not obliterate the error – this may be seen as an attempt to cover up a mistake.

30. Cross out error and initial

31. If an error is discovered after form is submitted: Preferably, in a different color of ink, draw a single line through the error, initial and date it, and add a note with the correct information If information was omitted, add a note with the correct information, the date and the EMT-Basic’s initials. Correction of Errors

32. Special Reporting Situations This is an incident where there are many patients and injuries. When there is not enough time to complete the form before the next call, the EMT-Basic will need to fill out the report later The local MCI plan should have some means of recording important medical information temporarily, e.g. triage tag, that can be used later to complete the form. The standard for completing the form in an MCI is not the same as for a typical call. The local plan should have guidelines. This is the only situation where a PCR may not be fully completed. Multiple Casualty Incident (MCI)

33. MCI Triage Tags

34. Special Situation Reports Used to document events that should be reported to local authorities, or to amplify and supplement primary report. Should be submitted in timely manner. Should be accurate and objective. The EMT-Basic should keep a copy for his own records The report, and copies, if appropriate, should be submitted to the authority described by local protocol. Infectious disease exposure Injuries to self/other providers Hazardous areas/scenes Social service referrals Child/elder abuse

35. PCR Summation Reports Continuous Quality Improvement Information gathered from the pre- hospital care report can be used to analyze various aspects of the EMS System. This information can then be used to improve different components of the system and prevent problems from occurring.