Documentation / EMSCHARTS

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

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

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

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

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.

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

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

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

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

(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?

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

Documenting RMA’s More is necessary

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

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

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

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

Set up of EMScharts Charting by exception

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