1. 10
Documentation

2. Multimedia Directory
Slide 33 Explaining Medical Terminology Video

3. Standard
Preparatory (Documentation)

4. Competency
Integrates comprehensive knowledge of EMS systems, the safety and well-being of the paramedic, and medical/legal and ethical issues, which is intended to improve the health of EMS personnel, patients, and the community.

5. Introduction
Prehospital care report (PCR): factual record of events that occur during EMS call or other patient contact.
Describes assessment and care throughout emergency call
Documents exactly what you did, when you did it, effects of interventions
Sole permanent, complete written record

6. Introduction PCR Three Major Goals
To provide information to subsequent health care professionals about patient and treatments provided in prehospital setting
To provide essential information for proper billing of patient
To provide legal record of the call's circumstances

7. Uses for Documentation
Medical
PCR can tell emergency department staff of patient's condition before arrival at hospital.
Baseline for comparing assessment findings and detecting trends that indicate improvement or deterioration

8. Uses for Documentation
Medical
Surgical staff: MOI and other findings during primary assessment.
Floor or intensive care unit staff: information about original condition.
Information from people at scene; circumstances that led to event or MOI

9. The run data in a prehospital care report is vital to your agency's efforts to improve patient care.

10. Uses for Documentation
Administrative
Gather information for quality improvement and system management.
Response times
Call location
Use of lights and siren
Date and time

11. Uses for Documentation
Research
Analyze recorded data to determine efficacy of medical devices or interventions.
Use data to cut costs, alter staffing, shorten response times.
Some systems use computerized or electronic PCRs and computerized database to analyze data.

12. The handheld electronic clipboard enables you to enter your prehospital care report directly into a computer. (© Kevin Link)

13. Uses for Documentation
Legal
PCR permanent part of patient's medical record.
Lawyers may refer to it when preparing court actions.
In legal proceeding, it might be sole source of information about the case.
May serve as evidence in criminal case

14. Uses for Documentation
Legal
Always write PCR as if you will have to refer to it someday in court proceeding.
Describe patient's condition when you arrived and during care, status on arrival at hospital.
Document condition before and after any interventions.
Avoid writing subjective opinions.
Points to Emphasize
Remind the students to write every run report as if they will have to explain it in five years in the future to a room full of people.

15. General Considerations
Every EMS system has its own specific requirements for documentation.
Reports with check boxes
Bubble sheets
Computerized documentation

16. General Considerations
Medical Terminology
Use appropriate medical terminology.
Abbreviations and Acronyms
Use correct abbreviations and acronyms.
Formed from initial letters of words they stand for
Class Activities
As a group, go over as many abbreviations and acronyms as can be thought of, along with the EMS meaning.

17. Standard Charting Abbreviations

18. Standard Charting Abbreviations (continued)

19. Standard Charting Abbreviations (continued)

20. Standard Charting Abbreviations (continued)

21. Standard Charting Abbreviations (continued)

22. Standard Charting Abbreviations (continued)

23. Standard Charting Abbreviations (continued)

24. Standard Charting Abbreviations (continued)

25. Standard Charting Abbreviations (continued)

26. Standard Charting Abbreviations (continued)

27. Standard Charting Abbreviations (continued)

28. Standard Charting Abbreviations (continued)

29. Standard Charting Abbreviations (continued)

30. Standard Charting Abbreviations (continued)

31. Standard Charting Abbreviations (continued)

32. Standard Charting Abbreviations (continued)

33. Explaining Medical Terminology Video
Questions:
Why is it important for paramedics to use appropriate medical terms?
Why is it important to understand prefixes, suffixes, roots, and stems when developing a medical vocabulary?
How can paramedics effectively implement their medical terminology?
Click here to view a video on the topic of medical terminology.
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34. General Considerations
Times
Times you record on PCR considered official times of incident.
For medical and legal purposes, ensure their accuracy.

35. General Considerations
Times
Time call received
Dispatch time
Time of arrival at scene
Time of departure from scene
Time of arrival at hospital
Time back in service
Record all times from same clock.

36. General Considerations
Communications
PCR likely only permanent record of your discussion with medical direction physician.
Document medical advice or orders you receive and results of implementing.
Document what you reported to physician and/or discussed.
Document physician's name.

37. General Considerations
Pertinent Negatives
Document all findings of assessment, even those that are normal.
Negative findings; vary for each chief complaint
Points to Emphasize
Discuss the importance of pertinent negatives, and how these negative statements reflect a thorough patient assessment.
Knowledge Application
Assign for homework a short number of medical complaints (e.g., shortness of breath, chest pain, headache) and have the students write out the pertinent negatives they would ask to rule out other problems.

38. General Considerations
Oral Statements
Statements of witnesses, bystanders, patient
Document MOI, patient's behavior, events leading up to emergency, first aid or medical care others rendered before you arrived
At crime scenes, document safety-related information.

39. General Considerations
Additional Resources
Document all resources involved in event:
Air-medical service
EMS, fire, rescue/extrication
Law enforcement agencies
Physicians/medical direction physicians
Document integration carefully.

40. Elements of Good Documentation
Completeness and Accuracy
Accurate PCR: precise but comprehensive.
Include all relevant information; exclude superfluous information.
Complete both narrative and check-box sections.
Narrative core of the documentation

41. Elements of Good Documentation
Completeness and Accuracy
Make sure information in checked boxes and narrative is consistent.
Use proper spelling, approved abbreviations, proper acronyms.

42. Elements of Good Documentation
Legibility
Poor penmanship and illegible reports lead to poor documentation.
Handwriting must be neat.
Other members of health care team may use report for medical information, research, or quality improvement.

43. Elements of Good Documentation
Timeliness
Avoid writing report in ambulance during transport of patient.
Complete paperwork once patient care is transferred.
Complete report immediately after emergency call.

44. Elements of Good Documentation
Absence of Alterations
If you make a mistake writing your report, simply cross through error with one line and initial it.
Do not scribble over or blacken out any area of call report.
Never try to hide an error.
If you find error after you've written several sentences, submit addendum.
Class Activities
Walk the students through writing a run report, showing examples of how to line out an error and nothing the importance of correct grammar and spelling, legible handwriting, etc.

45. The proper way to correct a prehospital care report is to draw a single line through the error, write the correct information beside it, and initial the change.

46. Elements of Good Documentation
Absence of Alterations
Whenever possible, have everyone involved in call read or reread PCR.
Make corrections before you submit report.
Write any addendum to your report as soon as you realize that you made error or that additional information needed.

47. Elements of Good Documentation
Professionalism
Write report in professional manner.
Write cautiously; avoid remarks that might be construed as derogatory.
Avoid jargon, slang, biased statements, irrelevant opinions.
Write and speak carefully.

48. Narrative Writing Narrative depicts call at length.
Describes assessment findings in detail
Narrative Sections
Subjective narrative
Objective narrative
Assessment/management plan

49. Narrative Writing Subjective Narrative
Information elicited during patient's history:
Chief complaint (CC)
History of present illness (HPI)
Past history (PH)
Current health status (CHS)
Review of systems (ROS)
Mechanism of injury (MOI)

50. Narrative Writing Objective Narrative
General impression; data through inspection, palpation, auscultation, percussion, diagnostic testing:
Vital signs
Physical exam
Tests

51. Narrative Writing Objective Narrative
Head-to-toe approach: well suited for any call when you perform entire physical exam.
Encourages you to be systematic and thorough
Appropriate for major trauma and serious medical emergencies

52. Narrative Writing Objective Narrative
Body systems approach: focuses on body systems instead of body areas.
Suited to screening/preadmission exams
In emergency medicine, focus only on system(s) involved in current illness or injury.
One of the most comprehensive approaches to documentation

53. Narrative Writing Assessment/Management Plan
Document what you believe to be patient's problem.
Field diagnosis (impression)
Rule out identifies diagnoses you believe emergency physician should evaluate.
Record complete management plan from start to finish.

54. Narrative Writing General Formats SOAP Format S = Subjective
O = Objective
A = Assessment
P = Plan

55. Narrative Writing General Formats CHART Format C = Chief complaint
H = History
A = Assessment
R = Rx (treatment)
T = Transport
Knowledge Application
Give the students a scenario and have them write out a narrative based on the SOAP and CHART formats.

56. Narrative Writing General Formats Patient Management
Preferred for some critical patients
Focus on managing variety of patient problems; not on conducting thorough history and physical exam.
Chronological account
Assessment and management of conditions

57. Narrative Writing General Formats Call Incident Approach
Emphasizes MOI, surrounding circumstances, how incident occurred.
Documenting trauma call with significant MOI
Suitable when events surrounding call might be significant.
Discussion Topics
Go over the four formats listed that aid in writing the narrative.

58. Special Considerations
Patient Refusals
Person not seriously ill or injured; does not want to go to hospital
Patient signs PCR “Refusal of Care,” and you return to service.
Patient refuses care even though he needs it; against medical advice (AMA).
Patients retain right to refuse treatment or transportation if competent.

59. Special Considerations
Patient Refusals
Document that you believe patient was competent to refuse care.
Document patient has adequate mental status and understands field diagnosis, alternative treatments, consequences of refusing care.
Record reason for refusing care.

60. Refusal of Care Documentation Checklist

61. Special Considerations
Patient Refusals
Inform of potential complications from injuries that might not be obvious.
Document any involvement of patient's family or friends.
May need to make clear possibility of patient's dying.

62. Special Considerations
Patient Refusals
In many systems, you must contact medical direction physician before allowing patient to refuse transport.
Note that you instructed him to call ambulance or go to emergency department if condition worsens.
Include narrative with quotations and statements from others on scene.

63. Special Considerations
Services Not Needed
Document transport was unnecessary.
Document any discussion you have with emergency physician.
If ambulance canceled en route, document canceling authority and time of notification.
Document if you arrive on scene and find no patients.

64. Special Considerations
Multiple Casualty Incidents
Multiple patients, mass casualties, and disasters have special documentation problems.
Weigh patients' needs against demand for complete documentation.
Document as much as possible, as quickly as possible, on PCR.

65. Special Considerations
Multiple Casualty Incidents
Complete documentation later as addendum.
Document only what you know to be factual and accurate.
Be familiar with local policies and procedures for documenting these situations.

66. Special Considerations
Multiple Casualty Incidents
Triage tag: patient's vital information—name, major injuries, vital signs, treatment, priority (urgent, nonurgent).
Affix it to patient; remains there throughout event
Transfer its information to PCR later.

67. Consequences of Inappropriate Documentation
Medical Consequences
Potentially most serious
Can affect patient care for hours/days after ambulance call ends
Good documentation now enables good care later.
Critical Thinking Questions
What would happen if you had a patient in cardiac arrest, your documentation was inappropriate, and the patient later died and the family brought a lawsuit against you for inadequate care?
Could you be held liable for negligence, even if you knew you did the care but did not document it?

68. Consequences of Inappropriate Documentation
Legal Consequences
Poor, incomplete, inaccurate documentation encourages anyone who is pursuing frivolous lawsuit.
Good documentation discourages such actions.
Remember: if it is not documented, you did not do it.
Points to Emphasize
If you didn't write it down, you didn't do it.

69. Electronic Patient Care Records
Benefits of Electronic PCR Systems
Greater ease of data collection and analysis
Consistent, uniform, easily read patient chart
Reduction of poor penmanship and spelling errors
Opportunity for EMS administrator to configure and alter the software.

70. Electronic Patient Care Records
Benefits of Electronic PCR Systems
Integration with dispatch software, billing services, regulatory agencies
Interface with medical devices
Better quality assurance processes, chart reviews, feedback to EMT or paramedic

71. Electronic Patient Care Records
Benefits of Electronic PCR Systems
Data “pick from” list: values presented and EMT selects item or items from list.
Graphic interface
Manual entry
Teaching Tip
Obtain an electronic clipboard for the students to view.

72. A graphic interface on ePCR. (© Zoll Medical Corporation)

73. Electronic Patient Care Records
Drawbacks of Electronic PCR Systems
Prohibitive cost
Fees for technical support, upgrades, support from software vendor
Requires personnel to administer and deal with day-to-day issues
Institutional reluctance; push-back from field crews

74. Closing
As paramedic you will assume responsibility for your documentation.
It is one of the most important parts of EMS call.
Ensuring documentation is complete, accurate, legible, appropriate is one of your professional responsibilities.

75. Closing Your report's confidentiality cannot be overemphasized.
Confidentiality is patient's legal right.
Electronic charting will become common in the future; effective documentation still applies.

76. Summary All EMS records should possess same basic attributes.
Appropriate terminology, proper spelling, accepted abbreviations and acronyms, accurate times are essential.

77. Summary
Description of assessment and interventions (pertinent negatives and communications with on-line physicians) important.
All personnel and resources involved in call must be documented.
Record must be accurate and precise, free of jargon, neatly written.

78. Summary
Corrections made properly, including use of addendum when appropriate.
Systems of documentation: CHART and SOAP formats; use one consistently.
Special situations (multiple patients and refusals of transportation) require extra attention.

79. Summary
Complete narrative and check boxes best way to ensure necessary information is documented.
Documentation one of the most important parts of EMS call.
Permanent record of ambulance call.