Prehospital Documentation Westchester County Department of Emergency Services

Objectives Identify the communication and documentation considerations for EMT’s, EMT/I’s and Paramedics Identify the communication and documentation considerations for EMT’s, EMT/I’s and Paramedics I want YOU to write a great PCR!

Objectives Required Data and “why” it’s required Required Data and “why” it’s required The Do’s and the Don’ts The Do’s and the Don’ts Types of Forms Types of Forms Reporting Errors Reporting Errors Identify the following:

First Things First….

Baseline Information –Patient Information Chief complaint Chief complaint LOC or mental status LOC or mental status Vital signs Vital signs

Non Patient Care Information Time EMS dispatched Time EMS dispatched Time EMS enroute Time EMS enroute Time EMS arrived at scene Time EMS arrived at scene Time EMS unit left scene Time EMS unit left scene Time EMS unit arrived at hospital Time EMS unit arrived at hospital Time patient care was transferred Time patient care was transferred Travel Time Scene Time Activation Time

Problems….. Information recorded incorrectly or left out Information recorded incorrectly or left out –write down what did or did not happen –steps taken to correct situation Falsifying information Falsifying information

If You Make a Mistake…. Draw line through error Draw line through error Initial and date Initial and date Write correct info next to it Write correct info next to it May add note with correct info May add note with correct info Do not erase or use correction fluid Do not erase or use correction fluid

Examples of Data Collection Written form Computerized Computerized

Good documentation reduces: Good documentation reduces: Litigation Litigation Complaints Complaints Therefore reduces overall risk to the EMS agency, profession, and YOU! Therefore reduces overall risk to the EMS agency, profession, and YOU!

QA & Research Better ways and methods for patient care Better ways and methods for patient care Protocols get changed Protocols get changed

QA & Research Potential problems identified Potential problems identified Best practices identified Best practices identified

PCR Writing – THE ACT!

Why Write a PCR? Prehospital care report serves six functions: Prehospital care report serves six functions: –Continuity of care –Legal documentation –Education –Administrative –Research –Evaluation and quality improvement

Remember……… Write clearly. Be objective. Be accurate. If you didn’t write it, you didn’t do it.

Don’t pre-judge Don’t pre-judge What’s the worse that could be going on What’s the worse that could be going on Be without bias or prejudice Be without bias or prejudice Chronic patients (Regulars) Chronic patients (Regulars) Wipe the slate clean Wipe the slate clean Remember………

State things concisely. State things concisely. Use short succinct sentences. Use short succinct sentences. K.I.S.S. K.I.S.S. Avoid long winded statements. Avoid long winded statements. Abbreviations (Accepted list). Abbreviations (Accepted list). Remember………

PCR’s Must Be…. Legible All in the same time frame Clear, not vague Easy to read Accurate Truthful

VITAL VISION Never record falsely, exaggerate, or make up data Incorrect spelling, grammar, and punctuation can be misleading, and makes you look uneducated. Objective information should be stated in a factual manner

Things to Think About…… Avoid/Hyphen - (minus/negative) Avoid/Hyphen - (minus/negative) Semicolon ; Connect related statements instead of using “Patient states” Semicolon ; Connect related statements instead of using “Patient states” Colon : A colon can be used instead of “is” Colon : A colon can be used instead of “is”

The 4 “P’s” Protection Protection Providers Providers Patient Patient Profession Profession

Profession Data Quality Improvement Risk Management Research

Rule #1 “DO NO HARM” Know your protocols Not sure? Speak to Medical Control Be objective with your treatment You never know it all. Rule #2 “USE COMMON SENSE”

You are not judge and jury. Try to do an assessment. Inform patient of ramifications. Must be an informed refusal. If they are: suicidal, have impaired judgment from drugs/alcohol..They have to be transported. Minors can’t refuse to go, contact Medical Control.

Get a signed refusal, witnessed preferably by someone other than your partner Document, document, document,……. Cancelled, unfounded, left before arrival etc. Document, document, …..

“You are going to wait for hours in the E.D. before you get seen.” “An ambulance is going to cost you $$$$” “Oh, you don’t want to go, okay see ya” “They wont do anything for you” “Someone could be dying while you’re tying us up with your bull #&^%”

“This could be related to your heart, it would be a good idea if you get checked out” “You bent the steering wheel with your chest, there is serious potential for internal injuries” “You know your family isn’t going to leave you alone unless you go”

Patient Document what is found at the scene Document what is found at the scene Document patients condition Document patients condition Provide subsequent providers with information to continue care Provide subsequent providers with information to continue care

“Food rotting on counter tops”“Food rotting on counter tops” “Apartment cold, heat turned off”“Apartment cold, heat turned off” “Refrigerator empty”“Refrigerator empty” “Large pile of newspapers and mail”“Large pile of newspapers and mail” “Lives alone unable to get out of bed”“Lives alone unable to get out of bed” “On the floor for 24 hrs, lg urine stain”“On the floor for 24 hrs, lg urine stain” Scene Assessment

Condition “Appeared in poor hygiene”“Appeared in poor hygiene” “Incontinent of old urine and feces”“Incontinent of old urine and feces” “Lethargic prior to O2 and warming”“Lethargic prior to O2 and warming” “Talking to relatives not there”“Talking to relatives not there” “Bradycardia”“Bradycardia”

The Continuum Medications Medications Allergies Allergies Family contacts Family contacts Findings/Treatment/Changes Findings/Treatment/Changes Written Run Report Written Run Report

The Major Malfunction… Chief Complaint ; “I have chest pain”, “I’m dizzy”, “I can’t breath” What the patient c/o. Chief Complaint ; “I have chest pain”, “I’m dizzy”, “I can’t breath” What the patient c/o. If unable to communicate ; Call nature (Man down), (Female collapsed) Use common sense judgment if it’s an unknown. If unable to communicate ; Call nature (Man down), (Female collapsed) Use common sense judgment if it’s an unknown. Came in as an unknown, friend states pt. drank a fifth of whiskey. Came in as an unknown, friend states pt. drank a fifth of whiskey.

Other examples of Subjective Prior level of function Prior level of function Lifestyle/home situation, scene survey Lifestyle/home situation, scene survey History from patient and witnesses History from patient and witnesses Major complaints Major complaints Emotions or attitudes Emotions or attitudes Goals Goals Response to treatment Response to treatment

Patient, Patient, Patient! Subjective should be brief and to the point. It is acceptable to use “Patient” the 1st time, after that it’s assumed, unless otherwise stated, that the information in this section came from the patient

Check Please! Put your narrative in chronological order with past medical history, history of present illness/injury, and changes as they occur. Put your narrative in chronological order with past medical history, history of present illness/injury, and changes as they occur. It makes your report easier to read and make sense. It makes your report easier to read and make sense. Do it the same way, EVERY TIME! Do it the same way, EVERY TIME!

The Patient Says…. Quoting can be the most appropriate method of conveying subjective information. Quoting can be the most appropriate method of conveying subjective information. VerbsStates, describes, denies, indicates, c/o. VerbsStates, describes, denies, indicates, c/o. Denial: “I don’t need to go to the hospital.” Denial: “I don’t need to go to the hospital.” Abusive language: “Keep your F#^%( hands off of me!” Abusive language: “Keep your F#^%( hands off of me!”

Don’t Go It Alone….. All of the following information was taken from the patient’s daughter: Lives with daughter and daughter’s husband. All of the following information was taken from the patient’s daughter: Lives with daughter and daughter’s husband. Per wife: “He hasn’t been feeling well for several days.” Per wife: “He hasn’t been feeling well for several days.”

Objective / Observations Measurements performed by the EMT. Measurements performed by the EMT. Observations by the EMT. Observations by the EMT. Compared results from treatment. Compared results from treatment. Primary and Secondary surveys. Primary and Secondary surveys.

When I Look at the Patient I See…. State of consciousness:A V P U, grimaces to pain, moans to voice, answers questions but is sleepy. General Appearance:Thin, Obese, Pink, warm, and dry, unkempt…….. Ataxic gait. Grip strength weaker on left. Breath sounds:Clear to auscultation. (CTA).

A ssessment Summary of the patients major problems. Summary of the patients major problems. Your sixth sense of what's going on. Your sixth sense of what's going on. Your impression. Your impression. Gives a reference point for others. Gives a reference point for others.

Examples ….. Chest pain, r/o M.I. Chest pain, r/o M.I. Acute abdominal pain, r/o etiology. Acute abdominal pain, r/o etiology. Acute exacerbation of COPD. Acute exacerbation of COPD. Respiratory arrest, 2° to exacerbation of asthma. Respiratory arrest, 2° to exacerbation of asthma. Multi-system Trauma. Multi-system Trauma.

Your written note must justify your treatment. Your written note must justify your treatment. If you omitted treatment make it clear why. If you omitted treatment make it clear why. If it’s not a standing order, Medical Control must be documented and orders received. If it’s not a standing order, Medical Control must be documented and orders received. Who gave you the orders to treat or withhold Rx. Who gave you the orders to treat or withhold Rx. Examples …..

P L A N of care Patient’s treatment plan (What you did) Patient’s treatment plan (What you did) Treatment progression Treatment progression Plans for assessment and reassessment Plans for assessment and reassessment Destination Destination Equipment used Equipment used Medications used Medications used Transfer of care Transfer of care Involvement of other agencies Involvement of other agencies

Subjective Don’t list irrelevant info. Info should demonstrate need for an ambulance. Chief complaint, brief and to the point. Rate pain on Borg Scale. Avoid documenting chronic complaints. Changes in mentation or function.

Objective Show baseline assessment. Show baseline assessment. Document changes. Document changes. Take vital signs, Q-15 min. if stable, Q-10 or less if unstable. At least two sets needed to determine stability. Take vital signs, Q-15 min. if stable, Q-10 or less if unstable. At least two sets needed to determine stability. Re-evaluate patient at least once document change or no change. Re-evaluate patient at least once document change or no change. Be careful in reporting mental status. Be careful in reporting mental status.

Assessment Suspected problem. Suspected problem. R/O or R/I conditions you are treating for or strongly suspect. R/O or R/I conditions you are treating for or strongly suspect. If unsure describe what you see. If unsure describe what you see.

Plan Treatment make it match the S, O, and A Treatment make it match the S, O, and A Appropriate destination Appropriate destination If your agency bills for service: If your agency bills for service: Medicare and Medicaid will audit and demand return of money

RMA Document assessment findings and care given or attempted. Document assessment findings and care given or attempted. Have the patient sign the form. Have the patient sign the form. Have a witness sign the form. (Not Partner). Have a witness sign the form. (Not Partner). Include a statement that you explained the consequences of refusing care to the patient. Include a statement that you explained the consequences of refusing care to the patient.

Reportable Issues Be familiar with required reporting in Westchester County, OSHA and your Agency. Be familiar with required reporting in Westchester County, OSHA and your Agency. –Gun shot wounds (crime scene). –Animal bites. –Infectious disease exposure. –Suspected physical or sexual abuse. –Elder or Child abuse. –Multiple casualty incidents.

Reporting Child, elderly, and disabled. Child, elderly, and disabled. Mandated reporters. Mandated reporters. Anonymous. Anonymous. Follow up. Follow up.

Five Ways to Improve Your Documentation Skills! 1. Paint a Picture. Your documentation is like a canvas. Use all your senses, and make your PCR easy to read.

2. Use Chronological Narratives. Keep things in chronological order. Don’t jump around! Five Ways to Improve Your Documentation Skills!

3. Stick to the Facts. A well-written patient care report is objective instead of subjective. Five Ways to Improve Your Documentation Skills!

4.Abandon Home-Grown Abbreviations. Five Ways to Improve Your Documentation Skills!

5. Spelling Counts. Your care may be of the highest standard, but if there are misspellings, your document becomes less credible. Five Ways to Improve Your Documentation Skills!

Questions and Answers