1. Documentation / EMSCHARTS

2. What is documentation?
A permanent legal document which provides a comprehensive account of information about the individual’s health care status.

3. Why document?
Clinical
Legal document which you may have to defend in court one day, years from incident
Data and statistics
Medical record which must be treated confidentially, as defined by HIPPA regulations
Education
Quality Management

4. Guidelines If it is not written down, it was not done.
If it was not done, do not write it down.

5. Characteristics of Strong Documentation
Complete
Clear
Concise
Accurate (including spelling)
Objective
Timely

6. Objective vs. subjective
Objective- intended to be unbiased
Subjective- usually based on fact, but it is someone’s interpretation of a fact
Ex: a. The patient was in a lot of pain.
b. The patient had mid-sternal chest pain which radiated into his back 8/10, sharp, consistent, negative increase in pain on palpation.

7. Approaches to Narrative (CHART System)
CHART- Chief Complaint, History, Assessment, Rx(Treatment), Transport
Other options: SOAP (Subjective findings, Objective findings, Assessment, Plan)

8. Chief complaint and history (C,H)- What you are told
History of Present Illness: OPQRST
Past Medical History: SAMPLE

9. What is a chief complaint?
“Reason EMS has been called, usually recorded in patient’s own words”
“Some cases the patient’s chief complaint is different from the reason EMS was called”
Source: Emergency Medical Technician EMT in Action, 2nd Edition, Barbara Aehlert, page 306, Published by McGraw-Hill, New York, NY, 2011

10. Assessment (A)- What you see/feel/hear
Trauma
-pt. appearance, surroundings, position
-head, nose, eyes, ear, throat
-neck
-chest
-abdomen, pelvis
-extremities
Cardiopulmonary
-neck- jugular veins, trach deviation
-chest – lung sounds, respiratory rate
-extremities- edema, pms
-other- oxygen sat level
AMS
-mental status (AVPU, orientation, memory, LOC?)
-pupils
-trauma assess

11. (Rx,Transport)- What you did
What was done for the patient?
How was patient moved to stretcher? To ambulance?
How did the patient respond?
Improvement or deteriorating condition during transport?
Where was patient brought? Who assumed care?

12. Principles of Writing the Narrative
Paint a picture
Try to be chronological
Include pertinent negatives
Describe, don’t conclude i.e. “patient was involved in MVA where he had damage to rear of vehicle” vs. “patient was rear-ended”
Record important observations on scene- i.e. damage to car, presence of weapons, pill bottles
Only use standard abbreviations
Include changes in pt. condition after treatment/during transport
Identify the source of information
Check spelling/grammar
Do not document interventions by medics

13. Documenting RMA’s
More is necessary

14. High-risk Refusals Abdominal Pain Chest Pain Electrical shock
Poisoning
Pregnancy related complaints
Water-related incidents
Falls >10 ft
Head Injury
Vehicle roll-over
High speed MVA
Auto vs. pedestrian or auto vs. bicyclist
Motorcycle crash speeds >20 MPH
Pediatric patient with medical complaint

15. Bare Necessities Patient name, age, DOB Hx, Rx, allergies
Two complete sets of vitals (or a good reason why not)
Mental status findings
Physical exam findings
Reason for refusal
Signed refusal form
Advice given by BLS
Acknowledgement that pt understands risks/dangers of refusal and possible outcomes

16. Patient was assessed
Trauma: rapid physical assessment, focused physical assessment, DCAP-BTLS
6 vitals signs: lung sounds, pulse, respiratory rate, blood pressure (cap refill <3 years old), pupils, skin condition

17. Back to basics
Respiratory Distress- lung sounds, respiratory rate, use of accessory muscles
AMS- normal mental state, how long has patient been altered, last seen normal, stroke test
Psych- threaten themselves or others, physically violent
Allergic reaction- known allergies, hives, itchiness, redness, difficulty breathing, meds

18. Set up of EMScharts
Charting by exception

19. EMSCharts Guidelines
All charts are to be entered within 24 hours of the call
All PCR’s will be QA’ed within 72 hours
All PCR’s should be entered at station or in ambulance