1. Chapter 6 Documentation
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2. Introduction
The field of EMS is based on competent, compassionate care that must be carefully documented
Competency, professional compassion, and accurately documenting medical calls protect Emergency Medical Responders (EMRs)
Good documentation begins with the EMR knowing the pertinent medical information that should be obtained from a patient and knowing the proper way to record and protect that information
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3. Patient Care Report Learning Objective 1
Legal record of the patient’s condition
Record of care that was provided during
the time spent with a patient
Important for continuity of
care and treatment
Legal issues
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4. Components of the Patient Care Report
Learning Objective 1
Components of the Patient Care Report
Call data
Patient data
Narrative information
Tells the story of what happened
Don’t use slang
Use military time
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5. Components of the Patient Care Report
Learning Objective 1
Components of the Patient Care Report
TRENDING VITAL SIGNS
Obtain multiple sets of vital signs
LOC and vital signs
May only have time for initial set
Trending must be done with all patients
Exception is a rapid transport patient
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6. Components of the Patient Care Report
Learning Objective 1
Components of the Patient Care Report
REFUSAL OF TREATMENT
Any competent adult may refuse medical assistance
Explain potential consequences
When to assume implied consent for treatment
Most EMS systems have a separate patient refusal form
If patient refuses to sign, indicate refusal on the form
Get a witness to sign form
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7. Components of the Patient Care Report
Learning Objective 1
Components of the Patient Care Report
TRANSFER OF CARE
Communicate both verbally and by
providing a copy of the PCR
In an emergency situation
Not enough time to read the PCR
EMR verbally communicates all pertinent information
SOAP or CHART format
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8. Subjective and Objective Information on PCR
Learning Objective 2
Subjective and Objective Information on PCR
OBJECTIVE INFORMATION
Data that can be observed and measured
Information that an EMR has personally seen upon physical examination
Can testify in court that it is factual
Can be verified by everyone
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9. Subjective and Objective Information on PCR
Learning Objective 2
Subjective and Objective Information on PCR
SUBJECTIVE INFORMATION
Information offered by the patient
Not objectively verifiable
Based on the opinions or feelings
EMR should never include her own opinions in narrative
Subjective information can be key to effectively assessing and managing a patient
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10. Explain Acronyms SOAP and CHART
Learning Objective 3
Explain Acronyms SOAP and CHART
SOAP OR CHART
Include in PCR
Do not repeat information
Give details in the narrative space
Systematic approach to patient
Document patient’s condition
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11. Explain Acronyms SOAP and CHART
Learning Objective 3
Explain Acronyms SOAP and CHART
SOAP CHARTING
S—Subjective information
O—Objective information
A—Assessment information
P—Patient care
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12. Explain Acronyms SOAP and CHART
Learning Objective 3
Explain Acronyms SOAP and CHART
CHART
C—Chief complaint
H—History
A—Assessment
R—Rx
T—Transport
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13. HIPAA and Emergency Medical Responders
Learning Objective 4
HIPAA and Emergency Medical Responders
HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA)
Specifically relates to the EMR
Protection of patient privacy
Protection of patient confidentiality
Security of health care information
Patient confidentiality and medical privacy is a legal requirement
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14. Summary
Good initial documentation of patient care can lead to clues regarding the patient’s condition through trending
Good documentation protects the EMR
The PCR is a legal document and may be used in a court of law
An EMR may use acronyms such as SOAP and CHART to provide a systematic approach for gathering and documenting patient medical information
EMRs are not allowed to give patient information to anyone except other health care providers
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