Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Paramedic Care: Principles & Practice Volume 2 Patient Assessment

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Chapter 6 Documentation

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Topics Uses for Documentation General Considerations Elements of Good Documentation Narrative Writing Special Considerations Consequences of Inappropriate Documentation

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Introduction The prehospital care report (PCR) is the only truly factual record of events. –Documents exactly what you did, when you did it, and the effects of your interventions. The PCR reflects your professionalism. The PCR has many uses.

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Uses for PCRs Medical Administrative Research Legal

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Uses for Documentation

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Uses for Documentation Medical use –Provides a chronological account of patient’s status –MOI, trends, bystander and witness information –Ensures your patient’s continuous effective care

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Uses for Documentation Administrative –Evaluates response times, call location, and date and time –Information about community needs –Quality assurance –Insurance and billing –Regional funding considerations

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Uses for Documentation Research –Gives researchers useful data about EMS –Data obtained will help determine efficacy of treatments –Information obtained will help provide continuous, quality patient care

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Uses for Documentation Legal –The PCR becomes a permanent part of your patient’s medical record. –Write your PCR as if you knew you would have to refer to it someday in a court proceeding. – A complete, accurate, and objective account is your best defense in court.

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ General Considerations

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ General Considerations Type of call record used varies from system to system –Check boxes, bubble sheets, or computer scanable –Electronic documentation Considerations are the same no matter what system is used © Jeff Forster

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ General Considerations Medical Terminology –Proper spelling reflects professionalism Abbreviations and Acronyms –Increase the amount of information you can write quickly May be confused if not accepted Incident Times –Ensure synchronization with dispatch

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ General Considerations Communications with Hospital –Document any medical advice or orders you receive and the results Pertinent Negatives Oral Statements by Patient or Bystanders –May include the disposition of valuables Additional Resources

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Elements of Good Documentation

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Elements of Good Documentation Completeness and Accuracy –You should complete both the narrative and check-box sections of every PCR. –Spelling, approved abbreviations, and proper acronyms also affect your PCR’s accuracy.

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Elements of Good Documentation Legibility –Handwriting must be neat enough that other people can read and understand the report. Timeliness –You should avoid writing your report in the ambulance during transport. –Complete your report immediately after you complete the emergency call.

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Elements of Good Documentation Absence of Alterations –Do not scribble over or blacken out any area of the call report. –Draw one line through a mistake and initial. –If necessary, attach an addendum.

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Elements of Good Documentation Professionalism –The PCR may be scrutinized by hospital staff, quality improvement committees, supervisors, lawyers, and the news media. –Do not include jargon, slang, or biased opinion.

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Narrative Writing

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Narrative Writing Narrative portion of the PCR allows for a chronological description of the call. It should be carefully detailed and legible.

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Narrative Writing PCR is a legal document and part of the patient’s medical record. Use of slang or medical abbreviations that are not universally accepted should be avoided.

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Narrative Writing Narrative has 3 main sections: –Subjective comprises any information you elicit during your patient’s history –Objective findings Body system approach Head-to-toe approach –Assessment/management plan

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ General Narrative Formats CHART –Chief complaint –History –Assessment –Rx (treatment) –Transport SOAP –Subjective –Objective –Assessment –Plan Other formats –Patient management –Call incident

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Special Considerations

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Special Considerations Patient refusals Services not needed Deviations from the standard Mass-casualty incidents

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Patient Refusals Patients retain the right to refuse treatment or transportation if they are competent to make that decision. Two main types of refusals: – The patient who is not seriously injured and does not want to go to the hospital. – The patient refuses even though you feel he needs it.

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ One Example of a “Refusal of Care” Form

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ A patient’s refusal of care requires careful documentation.

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Services Not Needed Some systems allow paramedics to determine patients that do not require ambulance transportation. The risks of denying transport are even greater than those of a refusal. Evaluate all patients with even minor injuries and document appropriately.

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Mass-Casualty Incidents Multiple patients, mass casualties, and disasters all present special documentation problems. Weigh your patient’s needs against the demand for complete documentation. Follow local guidelines and utilize the appropriate forms such as triage tags.

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Triage tags are used to record vital information on each patient quickly.

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Consequences of Inappropriate Documentation

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Consequences of Inappropriate Documentation Inappropriate documentation can have both medical and legal consequences. – Do not guess about your patient’s problems. – Write neatly, clearly, and legibly. – Complete your form completely. – Spelling counts!

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Summary Uses for Documentation General Considerations Elements of Good Documentation Narrative Writing Special Considerations Consequences of Inappropriate Documentation