Documentation /Charting Don Hudson, D.O.,FACEP/ACOEP

Documentation n Purposes –Preserves basic patient information –Records changes in patient condition –Justifies treatment –Allows continuity of care –Satisfies regulatory requirements –Provides data for quality control

Documentation n Protection for EMS personnel n Reflection of good patient care

Documentation An accurate, complete, legible medical record implies accurate, complete, organized assessment and management

Documentation n Characteristics of good medical record –Accurate –Complete –Legible –Free of extraneous information

Accurate n Document facts, observations only n Do NOT speculate about patient or incident n Double-check numerical entries n Recheck spellings of: –Persons –Locations –Medical terms

Accurate If you make a mistake, document it. It is better to record your own mistakes that for someone else to uncover them.

Complete n Include all requested information n If information requested does not apply, note “not applicable” or “N/A” n Include at least two sets of vital signs on every patient n Failure to document implies failure to consider n If you look for something and it isn’t there, document its absence

Complete IF IT ISN’T DOCUMENTED, IT WASN’T DONE!

Legible n If you cannot read the report, you may be unable to determine what happened n Documents presented in court must “speak for themselves” n If a document cannot be deciphered, the jury has to right to ignore it altogether

Legible If the report is sloppy, others will assume that the care was equally sloppy

Free of Extraneous Information n Avoid labeling patients (“drunk”, “psych patient”) n Describe the observations you made n Preface comments made by the patient with “per the patient” or “patient stated”

Free of Extraneous Information n Record hearsay only if applicable n Do NOT record hearsay as facts n Use quotation marks only if a statement is accurate word-for-word

Free of Extraneous Information Avoid interjecting humor The public does not regard EMS as a funny business

Documentation n A copy of the report must be left with the patient at the receiving hospital –State law requires this –Patient care has not legally been transferred until the receiving facility has your written report

Documentation n The person who rode with the patient writes the report n All personnel who participated in care should review the report

Documentation n If something needs to be corrected, correct it n The sooner an error is corrected, the more credible and reliable the change is n Mark through information so it is still readable n Then write in the new information and initial/date the change

Documentation If you have a long report, don’t hesitate to use additional pages

Documentation n Avoid stating diagnostic impressions n Report facts and observations n If you must state a diagnostic impression –Do so within the scope of your training –Include the observations that led to the impression

Documentation Avoid using “possible” or “?” when the observation would have been obvious to anyone

Documentation n Be sure treatments recorded match the mechanism of injury or the diagnostic impression n If something should have been done that was not, state why

Documentation n If spaces are provided for documenting times, fill them in carefully n Failing to document times implies lack of concern about the time factor n If you have a prolonged scene time, say why

Documentation If you put a monitor on the patient, a hard copy of the EKG should accompany the report

Documentation n If a patient complains of pain in a area, state what you found when you examined the area n Failure to record your observations implies that you noted the complaint, but did not investigate it

Documentation n On MVCs, report –Type of collision (head-on, roll-over, lateral impact, etc.) –Degree of damage to vehicles –Location of patients –Use of seatbelts

Documentation n On falls report: –Where the patient fell from –How far the patient fell –The surface the patient fell onto –Why the patient probably fell

Documentation n On head injuries report: –Level of consciousness –Pupillary responses

Documentation n On head injuries report: –Presence/absence of: »Discharge from nose and ears »Cervical pain, muscle spasm, tenderness, deformity »Paresthesias »Altered motor function »Altered sensory function

Documentation n On chest injuries report: –Position of trachea –Status of neck veins, breath sounds, heart sounds –Presence or absence of »Crepitus »Subcutaneous air »Paradoxical movement of chest wall

Documentation n On extremity injuries report: –Distal skin color and temperature –Presence or absence of: »Distal pulses »Motor function »Sensory function

Good Documentation is NOT C.Y.A Good Documentation is a Reflection of Good Patient Care