Chapter 6 Documentation EMR 6-1 1-

Introduction The field of EMS is based on competent, compassionate care that must be carefully documented Competency, professional compassion, and accurately documenting medical calls protect Emergency Medical Responders (EMRs) Good documentation begins with the EMR knowing the pertinent medical information that should be obtained from a patient and knowing the proper way to record and protect that information EMR 6-2 1-

Patient Care Report Learning Objective 1 Legal record of the patient’s condition Record of care that was provided during the time spent with a patient Important for continuity of care and treatment Legal issues EMR 6-3

Components of the Patient Care Report Learning Objective 1 Components of the Patient Care Report Call data Patient data Narrative information Tells the story of what happened Don’t use slang Use military time EMR 6-4

Components of the Patient Care Report Learning Objective 1 Components of the Patient Care Report TRENDING VITAL SIGNS Obtain multiple sets of vital signs LOC and vital signs May only have time for initial set Trending must be done with all patients Exception is a rapid transport patient EMR 6-5

Components of the Patient Care Report Learning Objective 1 Components of the Patient Care Report REFUSAL OF TREATMENT Any competent adult may refuse medical assistance Explain potential consequences When to assume implied consent for treatment Most EMS systems have a separate patient refusal form If patient refuses to sign, indicate refusal on the form Get a witness to sign form EMR 6-6

Components of the Patient Care Report Learning Objective 1 Components of the Patient Care Report TRANSFER OF CARE Communicate both verbally and by providing a copy of the PCR In an emergency situation Not enough time to read the PCR EMR verbally communicates all pertinent information SOAP or CHART format EMR 6-7

Subjective and Objective Information on PCR Learning Objective 2 Subjective and Objective Information on PCR OBJECTIVE INFORMATION Data that can be observed and measured Information that an EMR has personally seen upon physical examination Can testify in court that it is factual Can be verified by everyone EMR 6-8

Subjective and Objective Information on PCR Learning Objective 2 Subjective and Objective Information on PCR SUBJECTIVE INFORMATION Information offered by the patient Not objectively verifiable Based on the opinions or feelings EMR should never include her own opinions in narrative Subjective information can be key to effectively assessing and managing a patient EMR 6-9

Explain Acronyms SOAP and CHART Learning Objective 3 Explain Acronyms SOAP and CHART SOAP OR CHART Include in PCR Do not repeat information Give details in the narrative space Systematic approach to patient Document patient’s condition EMR 6-10

Explain Acronyms SOAP and CHART Learning Objective 3 Explain Acronyms SOAP and CHART SOAP CHARTING S—Subjective information O—Objective information A—Assessment information P—Patient care EMR 6-11

Explain Acronyms SOAP and CHART Learning Objective 3 Explain Acronyms SOAP and CHART CHART C—Chief complaint H—History A—Assessment R—Rx T—Transport EMR 6-12

HIPAA and Emergency Medical Responders Learning Objective 4 HIPAA and Emergency Medical Responders HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA) Specifically relates to the EMR Protection of patient privacy Protection of patient confidentiality Security of health care information Patient confidentiality and medical privacy is a legal requirement EMR 6-13

Summary Good initial documentation of patient care can lead to clues regarding the patient’s condition through trending Good documentation protects the EMR The PCR is a legal document and may be used in a court of law An EMR may use acronyms such as SOAP and CHART to provide a systematic approach for gathering and documenting patient medical information EMRs are not allowed to give patient information to anyone except other health care providers EMR 6-14 1-