DOCUMENTATION Finishing the Job

“ I first saw the slow-moving, sad faced old gentleman when he bounced off the hood of my car”

WHY?

WHY? Continuity of Care Quality Improvement Billing Data Collection Legal Protection

‘Coming home, I drove my car into the wrong house and collided with a tree I don’t have.’

WHAT? According to Montana Licensing Rules: ID of EMS provider Date of call Pt’s. name and address Type of run ID of all providers, riders, trainees, or service personnel officially responding to call

AND…. Time: Dispatch is notified EMS is notified EMS enroute Arrival on scene Left scene or turned over care Arrival at receiving hospital

AND…. Utilization of online medical control History of pt’s. illness/injury, including physical exam findings Treatment provided or offered VS including time taken Destination of patient

“In my attempt to kill a fly, I drove into a telephone pole.”

WHEN?? As soon as possible upon arrival at receiving facility, but no more than 48 hr. after end of pt. transport. Receiving hospital must receive copy of PCR

WHO? Primary care provider should write the narrative and pt. care findings. All providers should have input.

“ I pulled away from the side of the road, glanced at my mother-in-law in the other seat and headed over the embankment.”

Narrative Formats: Chronological Anatomical systems Soap Subjective (Stuff that people told you) Objective (Observations) Assessment (Actual problem) Plan (Plan for treatment)

What type is this? Dispatched by 911 to Penderson oil well site for a 29-year old male pt. involved in industrial accident. Upon arrival, I found pt. lying in lateral recumbent position, alert & oriented, airway patent, breathing non-labored, circulation adequate, pupils ERL, GCS 15. Pt. stated he fell from standing position, landing on right lower lumbar region of back. Pt. complained of pain in that area (9 out of 10) rendering him unable to walk. I assessed the back and extremities—CMS intact X 4, noted redness and swelling on back on lower right side. Immobilized pt. to long spine board, obtained baseline vital signs (listed above), and initiated transportation. I continued to monitor the pt. enroute, and his condition was unchanged. Arrived at SMH ER, transferred care to RN Lisa Fawcett.

Chris’ Format Document: What you saw. What you did. What happened after you did it.

If and when you write at all. If you write at all You must write it all Because the law presumes You wrote it all, If and when you write at all.

And…. Treatment should reflect assessment. Document need for emergency transport.

No-Nos Do not use unapproved abbreviations. Do not inject opinions. Watch punctuation. Use appropriate, properly spelled medical terms or don’t use them at all. Don’t use medical slang. Don’t scribble out or write over mistakes.

(called out for male patient with shortness of breath) Arrived on scene Pt. was sitting in recliner in living room and in back pain! Pt’s. O2 sat was good—vitals were good, (vitals: pulse 80-100, resp. 20, BP 128/71, Pox 96%) Pt. stated he has had back pain for several years. Pt. stated he had no other medical problems, Pt’s meds were gathered and brought with. Pt. was assisted to stair chair then to stretcher. Pt. was a little agitated.

Pt. lying in bed—cool, clammy, slow to respond Pt. lying in bed—cool, clammy, slow to respond. Opened eyes when talked to—unable to talk. Caregivers stated they found her this way on room check. Pt. incontinent of urine/stool. Skin cool, clammy Pt. naked. Pt given 1 tube glutose—able to swallow. Pulse weak, thready. Pt. attempted to speak following glutose-could say words but unable to understand. Pt. lifted onto cot with 5 people. Pox improved with addition of O2—NRB 15L. Caregivers stated pt was fine last night. No known illness—ate a good supper. Caregiver also stated pt was ok at 1230—Enroute—pt. started vomiting—clear yellow emesis—suction used to clear airway. Medication/allergy list given to Nurse (name). Pt. not normally on home O2 .

My favorite… 12/03/83 dispatch time 0903 35-y.o. male VS: P strong/reg equal R 14 Suspected injury/illness: snowmobile acc. poss fx forearms & Lt ankle, lac. Rt side cheek Notes/medical history: NPH, NKA, NKM, splinted both forearms & wrapped in blankets, placed on scoop Emergency care rendered: Neck/spine immobilization (per scoop stretcher) box checked on scene but not enroute

“an invisible car came out of nowhere, struck my vehicle and vanished

Can we change the chart? Written policy: Only the original author should make modifications. All entries made after the PCR is initially completed should be signed and dated. Addendums should be cross-referenced to original PCR All who signed the PCR should be notified of changes/addendums.

(0625) Pt. slumped on floor against bed on EMS arrival-in sitting position with positional airway. Snoring respirations-thick secretions noted on face et beard. Pt. initially unresponsive. Family stated pt. had a seizure lasting 1-2 minutes prior to calling EMS. Airway positioned via jaw thrust. Oxygen applied via NRB @ 15 LPM. Pt. became combative, flinging arms, et struggling against responders. Unable to assess vitals due to pt. response. Difficult extrication due to large size of pt, small quarters. Pt. placed on backboard, backboard slid out of bedroom to cot. After pt. loaded to ambulance (0648) he had another seizure lasting 1 ½ minutes-head movement noted to L. Pupils unresponsive. Assisted with airway management in ICU. Pt’s arms were restrained with Kurlex bandage to protect patient during move. (See addendum)

Addendum: 12/29/07 PCR # 31657 Pt. had c/o severe headache for past 2 days—per wife. Large amt. of phlegm/mucous noted in waste can & on floor. Pt. incontinent of urine. Sheriff (name) on scene to assist. Signed and dated by all responders.

Refusals A3E3P3 Assess Advise Avoid Ensure Explain Exploit Persist Protocol Protect

Law enforcement on scene on our arrival. Pt Law enforcement on scene on our arrival. Pt. had been unresponsive prior to EMS arrival per Sgt. Ulrickson. On EMS arrival Pt. was awake, agitated and refused assessment, treatment or transport. No injuries noted on visual assessment. Pt. denied injury. Stated he laid down on sidewalk to ‘take a power nap’. Pt. able to move all extremities equally—insisted on standing up. Gait unsteady. Alert to time, place, date. Refusal signed. Pt. advised he could call EMS or seek further medical assistance at any time. Pt. escorted home by friends.

REMEMBER: If it wasn’t written down, you didn’t do it, see it, treat it or prepare for it.

Documentation Scenarios EMT-B Course

Me Neither……. 2325 dispatched to possible diabetic emergency 51 y.o. male with history of diabetes

Plan of Action Assess for responsiveness Complete initial assessment Check blood sugar If conscious and symptomatic, administer glutose Re-assess Transport?

On-Scene @ 2327 Wife meets EMS @ door. States husband is seizing in bedroom

General Impression Wife states she was flushing husband. “Looks like Billy clogged up the toilet again.”

General Impression: Oh, Fudge!! Noted pt. in full seizure Connected to a strange machine

Facts: Seizure was witnessed by EMS for approx. 8 minutes. Blood sugar was 33 about ½ hr. ago. Pt. was on home dialysis. Pt. woke up after seizure stopped. Pt. is on home dialysis. Oxygen was applied. Pt. was aware of his environment. Vital signs were not taken due to seizure activity. Airway was positioned manually. Dialysis tubing was clamped and disconnected from pt.’s port. Respirations were snoring. Seizure stopped @ 2334. Oxygen was applied at 15 l./min per non-rebreather mask.

Outcome: Left scene 2336 Arrived @ hospital @ 2337 Pt. ambulating in ER by 0015 Pt. shared that he has a manual for dialysis machine Later had to have shunt replaced Pt. received kidney transplant last winter and is doing well

I’ve Fallen and I Can’t Get Up….. 2212 Dispatched to local residence 62 y.o. male pt. has fallen and unable to get up—no injuries

General impression: Arrive on scene @ 2219 Morbidly obese pt. below knee amputation—right leg. Hx. Diabetes GCS 15—alert and oriented Denied injury or pain Abrasions noted to both knees

Assessment Pt. stated he had been having diarrhea since this morning Had fallen while enroute to bathroom Wife and 2 neighbors unable to assist pt. from floor Trauma assessment done with no injury found

Moving right along…. Lifted pt. to wheelchair with assist of 3 EMS, wife, and 2 neighbors Used the megamover to lift pt. Pt. denied need for transport Cot returned to rig EMS cleansed knee abrasions Initiated VS—P. 54 Sats 94% Resp. 22 labored, Blood sugar 332

And then…..@ 2232 Snoring respirations and decreased LOC—GCS 3 No palpable pulse

Treatment CPR initiated Pt. moved to floor Cot, Code Kit and rest of team retrieved AED applied, shock X 1 @ 2333 Assisted ventilation utilizing bag-valve mask and oxygen. Oral airway inserted. Transport delayed while waiting for requested assistance to move pt.

Response: Left scene @ 2243 CPR continued enroute @ hospital @ 2244—cardiac monitor shows V Tach

Outcome Pt. became responsive in CCU Had been intubated, but was able to communicate Flown to Bismarck Died 2 weeks later from repeat MI

Case of the Wooden Spoon 0200 dispatched to rural area for a male pt. Possible stroke

First Impression Wife met us at the door with a large wooden spoon in her hand. ?????

General Impression: Pt. sitting in chair in bedroom, clutching left shoulder Color gray, skin diaphoretic c/o left shoulder pain/weakness

Assessment Oriented but slow to respond to questions Airway clear Breathing slightly rapid Unable to palpate radial pulse Carotid pulse weak Unable to obtain BP

Treatment High flow oxygen Position of comfort Transport

Enroute Rookie EMT asks stupid question Pt. answered: “fell off my horse yesterday”

Outcome: Pt. was in hypovolemic shock due to ????? ruptured spleen

Lessons Learned: Spleen injury refers to left shoulder There is no such thing as a stupid question.

The rookie EMT is now an ER physician in Minneapolis Side Note: The rookie EMT is now an ER physician in Minneapolis

Case Study # 3 0909 dispatched to local drug store for ‘elderly male who has passed out’ 0917 Arrived on-scene

Scene size-up Elderly male sitting in chair at check-out counter Pharmacist diverted first EMT to give an account of events leading up to activating EMS ‘Slim’ had come in to get his hearing aid batteries replaced and wanted his NTG Rx refilled Slim was standing out check-out and bent over, laying his head on the counter—did not totally lose consciousness or fall. Slim stated that all he could see was a ‘white wall’

Size-up/Initial Assessment Pharmacist expressed his concern that Slim was not capable of driving himself at this point. Slim stated the following: He did not need an ambulance He did not call the ambulance He was not going to pay for the ambulance Pharmacist would not fill his ‘dynamite’ pills until he contacted Slim’s provider

Assessment Findings: 78 y.o. male Alert/oriented to time, place, event Color pale/ skin diaphoretic Radial pulse 64/ regular/weak BP 72/40 Unable to obtain Oxygen sat level (hands felt cold) Hx: CAD, Arteriosclerosis, emphysema, 2 coronary stints

Further assessment findings: Pt. is severely hearing impaired Walks with a cane s/p 2 hip replacements Wife is in hospital When questioned about medications pt. stated “heart meds—Dr. knows what I take” 2nd pulse check: 88/irregular

Responder Suspicions?? Dehydrated? Low blood sugar? Stress? Hypotension due to???

Next question…… Did you take your meds? Did you take a NTG? Were you having chest pain?

Challenges: Communication due to hearing loss Poor historian Refusal for transport My Dad

Outcome: 0929 Pt. was transported to hospital per daughter’s insistence Pt. was given IV fluids and instructed by Provider to take NTG only for chest pain Pt. admitted to hospital over night for evaluation Daughter still not forgiven.

Ponderings??