Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Chapter 14 Documentation

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory U.S. DOT Objectives Directory U.S. DOT Objectives are covered and/or supported by the PowerPoint Slide Program and Notes for Emergency Care, 11th Ed. Please see the Chapter 14 correlation below. *KNOWLEDGE AND ATTITUDE Explain the components of the written report and list the information that should be included in the written report. Slides Identify the various sections of the written report. Slides 8-9, Describe what information is required in each section of the prehospital care report and how it should be entered. Slides 8-9, Define the special considerations concerning patient refusal. Slides Describe the legal implications associated with the written report. Slides 5-6, Discuss all state and/or local record and reporting requirements. Slides Explain the rationale for patient care documentation. Slides (cont.)

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory U.S. DOT Objectives Directory *KNOWLEDGE AND ATTITUDE Explain the rationale for the EMS system gathering data. Slides 6-7, 15, Explain the rationale for using medical terminology correctly. Slide Explain the rationale for using an accurate and synchronous clock so that information can be used in trending. Slide 1717 (cont.)

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory U.S. DOT Objectives Directory *SKILLS Complete a prehospital care report.

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory The Prehospital Care Report (PCR)

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Functions: – Continuity of care – Legal document – Quality improvement Prehospital Care Report (cont.)

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Functions: – Education – Billing information – Statistics – Research Prehospital Care Report

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Prehospital Care Report (Handwritten)

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Prehospital Care Report (Computerized)

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Pen-Based Computer and PDA

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Each piece of information is an element (i.e., vital signs). U.S. DOT defines minimum elements for a PCR. PCR Data Set

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Patient Information Gathered at the time of the EMT’s initial contact with patient on arrival at scene, following all interventions, and on arrival at facility Minimum Data (cont.)

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Minimum Data Patient information: –Chief complaint –Level of consciousness (AVPU), mental status –Systolic BP for patients more than 3 years of age

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Skin perfusion (capillary refill) for patients less than 6 years of age Skin color and temperature Pulse rate Respiratory rate and effort Patient Information

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Time of incident report Time unit notified Time of arrival at patient Time unit left scene Time of arrival at destination Time of transfer of care Administrative Information

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Data Sections of the PCR

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Run Data

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Patient Data

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Treatment Given

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Narrative (cont.)

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Avoid conclusions—be objective. Include observations of the scene. Include pertinent negatives. Narrative (cont.)

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Avoid slang and radio codes. Use only standard abbreviations. Use correct spelling. Write legibly. Narrative

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Confidentiality –Regulated by the Health Insurance Portability and Accountability Act (HIPAA) –Completed reports must be kept in a locked box Distribution of copies –Determined by local and state regulations Prehospital Care Report

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Leads to poor patient care May lead to revocation of certification/license Falsification of PCR (cont.)

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory If an error in patient care occurs, document what did or didn’t happen. Then, note steps taken (if any) to correct the situation. Falsification of PCR

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Draw a single horizontal line through the error. Write the correct information beside it. Do not obliterate the error. Correction of Errors (cont.)

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Correction of Errors If an error is discovered after the form is submitted: –Use a different color of ink. –Correct error with a single-line cross out. –Initial and date the correction.

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Make sure the patient can make an informed, rational decision. Competent adult patients may legally refuse treatment. –Age? –Impaired by alcohol/drugs? –Mentally competent? –Impaired by medical condition? Patient Refusal (cont.)

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Patients must be informed of the consequences of refusing care. Document all assessment findings. Have patient sign refusal form. Have witness sign refusal form. Patient Refusal (cont.)

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Document attempts made to convince patient to go to hospital. Document actions taken to protect patient after you leave. Contact medical direction, if necessary. Patient Refusal

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Special Documentation Issues

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Special Reporting Situations Multiple-casualty incident (MCI): –Insufficient time to fully complete a PCR –Use local forms or “tags” on the scene. –Follow local MCI plan for documentation.

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory MCI Triage Tags

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Infectious disease exposure Injuries to self/other providers Hazardous areas/scenes Social service referrals Child/elder abuse Special Situation Reports (cont.)

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Document unusual events. Provide additional supplements to PCR. Follow local guidelines for confidentiality. Special Situation Reports

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Alternative methods used for PCR charting: –SOAP Subjective Objective Assessment Plan Enrichment (cont.)

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Alternative methods used for PCR charting: –CHART Chief complaint History Assessment Rx—treatment Transport Enrichment

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory 1. Explain the term minimum data and why it is important. 2. Explain what is meant by “objective” and “subjective” information in the narrative portion of the prehospital care report. Explain what is meant by “a pertinent negative.” Review Questions (cont.)

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory 3. Explain how spelling and the use of codes, abbreviations, and medical terms relate to writing a clear and accurate narrative report. 4. List some important steps to take and information to include when documenting a patient refusal. Review Questions (cont.)

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory 5. Describe some possible consequences of falsifying information on a prehospital care report. 6. Describe how to properly correct an error in a prehospital care report. Review Questions

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory What information is important to include in the prehospital care report? What is the importance of doing an accurate and thorough prehospital care report? Street Scenes (cont.)

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Should you have your partner read and comment on the prehospital care report before considering it complete? Street Scenes (cont.)

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory What are the ramifications of having a prehospital care report in the hospital record that is different from the original copy on file with your EMS agency? Street Scenes