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DOCUMENTATION Finishing the Job.

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Presentation on theme: "DOCUMENTATION Finishing the Job."— Presentation transcript:

1 DOCUMENTATION Finishing the Job

2 “ I first saw the slow-moving, sad faced old gentleman when he bounced off the hood of my car”

3 WHY?

4 WHY? Continuity of Care Quality Improvement Billing Data Collection
Legal Protection

5 ‘Coming home, I drove my car into the wrong house and collided with a tree I don’t have.’

6 WHAT? According to Montana Licensing Rules: ID of EMS provider
Date of call Pt’s. name and address Type of run ID of all providers, riders, trainees, or service personnel officially responding to call

7 AND…. Time: Dispatch is notified EMS is notified EMS enroute
Arrival on scene Left scene or turned over care Arrival at receiving hospital

8 AND…. Utilization of online medical control
History of pt’s. illness/injury, including physical exam findings Treatment provided or offered VS including time taken Destination of patient

9 “In my attempt to kill a fly, I drove into a telephone pole.”

10 WHEN?? As soon as possible upon arrival at receiving facility, but no more than 48 hr. after end of pt. transport. Receiving hospital must receive copy of PCR

11 WHO? Primary care provider should write the narrative and pt. care findings. All providers should have input.

12 “ I pulled away from the side of the road, glanced at my mother-in-law in the other seat and headed over the embankment.”

13 Narrative Formats: Chronological Anatomical systems Soap
Subjective (Stuff that people told you) Objective (Observations) Assessment (Actual problem) Plan (Plan for treatment)

14 What type is this? Dispatched by 911 to Penderson oil well site for a 29-year old male pt. involved in industrial accident. Upon arrival, I found pt. lying in lateral recumbent position, alert & oriented, airway patent, breathing non-labored, circulation adequate, pupils ERL, GCS 15. Pt. stated he fell from standing position, landing on right lower lumbar region of back. Pt. complained of pain in that area (9 out of 10) rendering him unable to walk. I assessed the back and extremities—CMS intact X 4, noted redness and swelling on back on lower right side. Immobilized pt. to long spine board, obtained baseline vital signs (listed above), and initiated transportation. I continued to monitor the pt. enroute, and his condition was unchanged. Arrived at SMH ER, transferred care to RN Lisa Fawcett.

15 Chris’ Format Document: What you saw. What you did.
What happened after you did it.

16 If and when you write at all.
If you write at all You must write it all Because the law presumes You wrote it all, If and when you write at all.

17 And…. Treatment should reflect assessment.
Document need for emergency transport.

18 No-Nos Do not use unapproved abbreviations. Do not inject opinions.
Watch punctuation. Use appropriate, properly spelled medical terms or don’t use them at all. Don’t use medical slang. Don’t scribble out or write over mistakes.

19 (called out for male patient with shortness of breath)
Arrived on scene Pt. was sitting in recliner in living room and in back pain! Pt’s. O2 sat was good—vitals were good, (vitals: pulse , resp. 20, BP 128/71, Pox 96%) Pt. stated he has had back pain for several years. Pt. stated he had no other medical problems, Pt’s meds were gathered and brought with. Pt. was assisted to stair chair then to stretcher. Pt. was a little agitated.

20 Pt. lying in bed—cool, clammy, slow to respond
Pt. lying in bed—cool, clammy, slow to respond. Opened eyes when talked to—unable to talk. Caregivers stated they found her this way on room check. Pt. incontinent of urine/stool. Skin cool, clammy Pt. naked. Pt given 1 tube glutose—able to swallow. Pulse weak, thready. Pt. attempted to speak following glutose-could say words but unable to understand. Pt. lifted onto cot with 5 people. Pox improved with addition of O2—NRB 15L. Caregivers stated pt was fine last night. No known illness—ate a good supper. Caregiver also stated pt was ok at 1230—Enroute—pt. started vomiting—clear yellow emesis—suction used to clear airway. Medication/allergy list given to Nurse (name). Pt. not normally on home O2 .

21 My favorite… 12/03/83 dispatch time 0903 35-y.o. male
VS: P strong/reg equal R 14 Suspected injury/illness: snowmobile acc. poss fx forearms & Lt ankle, lac. Rt side cheek Notes/medical history: NPH, NKA, NKM, splinted both forearms & wrapped in blankets, placed on scoop Emergency care rendered: Neck/spine immobilization (per scoop stretcher) box checked on scene but not enroute

22 “an invisible car came out of nowhere, struck my vehicle and vanished

23 Can we change the chart? Written policy:
Only the original author should make modifications. All entries made after the PCR is initially completed should be signed and dated. Addendums should be cross-referenced to original PCR All who signed the PCR should be notified of changes/addendums.

24 (0625) Pt. slumped on floor against bed on EMS arrival-in sitting position with positional airway. Snoring respirations-thick secretions noted on face et beard. Pt. initially unresponsive. Family stated pt. had a seizure lasting 1-2 minutes prior to calling EMS. Airway positioned via jaw thrust. Oxygen applied via 15 LPM. Pt. became combative, flinging arms, et struggling against responders. Unable to assess vitals due to pt. response. Difficult extrication due to large size of pt, small quarters. Pt. placed on backboard, backboard slid out of bedroom to cot. After pt. loaded to ambulance (0648) he had another seizure lasting 1 ½ minutes-head movement noted to L. Pupils unresponsive. Assisted with airway management in ICU. Pt’s arms were restrained with Kurlex bandage to protect patient during move. (See addendum)

25 Addendum: 12/29/07 PCR # 31657 Pt. had c/o severe headache for past 2 days—per wife. Large amt. of phlegm/mucous noted in waste can & on floor. Pt. incontinent of urine. Sheriff (name) on scene to assist. Signed and dated by all responders.

26 Refusals A3E3P3 Assess Advise Avoid Ensure Explain Exploit Persist
Protocol Protect

27 Law enforcement on scene on our arrival. Pt
Law enforcement on scene on our arrival. Pt. had been unresponsive prior to EMS arrival per Sgt. Ulrickson. On EMS arrival Pt. was awake, agitated and refused assessment, treatment or transport. No injuries noted on visual assessment. Pt. denied injury. Stated he laid down on sidewalk to ‘take a power nap’. Pt. able to move all extremities equally—insisted on standing up. Gait unsteady. Alert to time, place, date. Refusal signed. Pt. advised he could call EMS or seek further medical assistance at any time. Pt. escorted home by friends.

28 REMEMBER: If it wasn’t written down, you didn’t do it, see it, treat it or prepare for it.

29 Documentation Scenarios
EMT-B Course

30 Me Neither……. 2325 dispatched to possible diabetic emergency
51 y.o. male with history of diabetes

31 Plan of Action Assess for responsiveness Complete initial assessment
Check blood sugar If conscious and symptomatic, administer glutose Re-assess Transport?

32 On-Scene @ 2327 Wife meets EMS @ door. States husband is seizing
in bedroom

33 General Impression Wife states she was flushing husband.
“Looks like Billy clogged up the toilet again.”

34 General Impression: Oh, Fudge!!
Noted pt. in full seizure Connected to a strange machine

35 Facts: Seizure was witnessed by EMS for approx. 8 minutes.
Blood sugar was 33 about ½ hr. ago. Pt. was on home dialysis. Pt. woke up after seizure stopped. Pt. is on home dialysis. Oxygen was applied. Pt. was aware of his environment. Vital signs were not taken due to seizure activity. Airway was positioned manually. Dialysis tubing was clamped and disconnected from pt.’s port. Respirations were snoring. Seizure 2334. Oxygen was applied at 15 l./min per non-rebreather mask.

36 Outcome: Left scene 2336 Arrived @ hospital @ 2337
Pt. ambulating in ER by 0015 Pt. shared that he has a manual for dialysis machine Later had to have shunt replaced Pt. received kidney transplant last winter and is doing well

37 I’ve Fallen and I Can’t Get Up…..
2212 Dispatched to local residence 62 y.o. male pt. has fallen and unable to get up—no injuries

38 General impression: Arrive on scene @ 2219
Morbidly obese pt. below knee amputation—right leg. Hx. Diabetes GCS 15—alert and oriented Denied injury or pain Abrasions noted to both knees

39 Assessment Pt. stated he had been having diarrhea since this morning
Had fallen while enroute to bathroom Wife and 2 neighbors unable to assist pt. from floor Trauma assessment done with no injury found

40 Moving right along…. Lifted pt. to wheelchair with assist of 3 EMS, wife, and 2 neighbors Used the megamover to lift pt. Pt. denied need for transport Cot returned to rig EMS cleansed knee abrasions Initiated VS—P. 54 Sats 94% Resp. 22 labored, Blood sugar 332

41 And then…..@ 2232 Snoring respirations and decreased LOC—GCS 3
No palpable pulse

42 Treatment CPR initiated Pt. moved to floor
Cot, Code Kit and rest of team retrieved AED applied, shock X 2333 Assisted ventilation utilizing bag-valve mask and oxygen. Oral airway inserted. Transport delayed while waiting for requested assistance to move pt.

43 Response: Left scene @ 2243 CPR continued enroute
@ 2244—cardiac monitor shows V Tach

44 Outcome Pt. became responsive in CCU
Had been intubated, but was able to communicate Flown to Bismarck Died 2 weeks later from repeat MI

45 Case of the Wooden Spoon
0200 dispatched to rural area for a male pt. Possible stroke

46 First Impression Wife met us at the door with a large wooden spoon in her hand. ?????

47 General Impression: Pt. sitting in chair in bedroom, clutching left shoulder Color gray, skin diaphoretic c/o left shoulder pain/weakness

48 Assessment Oriented but slow to respond to questions Airway clear
Breathing slightly rapid Unable to palpate radial pulse Carotid pulse weak Unable to obtain BP

49 Treatment High flow oxygen Position of comfort Transport

50 Enroute Rookie EMT asks stupid question
Pt. answered: “fell off my horse yesterday”

51 Outcome: Pt. was in hypovolemic shock due to ????? ruptured spleen

52 Lessons Learned: Spleen injury refers to left shoulder
There is no such thing as a stupid question.

53 The rookie EMT is now an ER physician in Minneapolis
Side Note: The rookie EMT is now an ER physician in Minneapolis

54 Case Study # 3 0909 dispatched to local drug store for ‘elderly male who has passed out’ 0917 Arrived on-scene

55 Scene size-up Elderly male sitting in chair at check-out counter
Pharmacist diverted first EMT to give an account of events leading up to activating EMS ‘Slim’ had come in to get his hearing aid batteries replaced and wanted his NTG Rx refilled Slim was standing out check-out and bent over, laying his head on the counter—did not totally lose consciousness or fall. Slim stated that all he could see was a ‘white wall’

56 Size-up/Initial Assessment
Pharmacist expressed his concern that Slim was not capable of driving himself at this point. Slim stated the following: He did not need an ambulance He did not call the ambulance He was not going to pay for the ambulance Pharmacist would not fill his ‘dynamite’ pills until he contacted Slim’s provider

57 Assessment Findings: 78 y.o. male Alert/oriented to time, place, event
Color pale/ skin diaphoretic Radial pulse 64/ regular/weak BP 72/40 Unable to obtain Oxygen sat level (hands felt cold) Hx: CAD, Arteriosclerosis, emphysema, 2 coronary stints

58 Further assessment findings:
Pt. is severely hearing impaired Walks with a cane s/p 2 hip replacements Wife is in hospital When questioned about medications pt. stated “heart meds—Dr. knows what I take” 2nd pulse check: 88/irregular

59 Responder Suspicions?? Dehydrated? Low blood sugar? Stress?
Hypotension due to???

60 Next question…… Did you take your meds? Did you take a NTG?
Were you having chest pain?

61 Challenges: Communication due to hearing loss Poor historian
Refusal for transport My Dad

62 Outcome: 0929 Pt. was transported to hospital per daughter’s insistence Pt. was given IV fluids and instructed by Provider to take NTG only for chest pain Pt. admitted to hospital over night for evaluation Daughter still not forgiven.

63 Ponderings??

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