Chapter 4 Documentation Copyright ©2010 by Pearson Education, Inc. All rights reserved. Prehospital Emergency Care, Ninth Edition Joseph J. Mistovich Keith J. Karren

CASE STUDY Dispatch

EMS Unit 17 Respond to 57 Vallejo Road for a vehicle versus a parked car Time out 1321

Upon Arrival Female party who called 911 indicates the male who struck her vehicle was slumped over wheel States now he seems okay As you approach a mid-30s male he states, “Great! As if I didn’t have enough trouble today, I’ve got to deal with you guys! Go away. I don’t need any help!”

How would you proceed?

Back to Topics Functions of the Prehospital Care Report

Continuity of Medical Care Back to Objectives

Provides a baseline for other providers Gives an understanding of events and reasons for the call

Administrative Uses

Becomes part of patient record Used for billing Statistics

Legal Document

Is legal document May appear as a witness Can be months or years later May be a defense

Educational and Resource Uses

Can look at positive or negative effects May identify training needs

Evaluation and Continuous Quality Improvement

Documentation part of quality improvement Medical oversight

Back to Topics Collection of Data in Prehospital Care Reports

PCR Formats Back to Objectives

Written Computerized

PCR Data The Minimum Data Set Back to Objectives

Chief complaint Level of responsiveness Blood pressure Skin color, temperature, and condition Pulse rate Respiratory rate and effort Patient demographics Times of the call

PCR Data Administrative Information Back to Objectives

EMS unit and run or call number Names of crew and levels of certification Address to which unit is dispatched

PCR Data Patient Demographics and Other Patient Data

Legal name, age, sex, race, and birth date Home address Location where you found the patient Insurance/billing Care rendered prior to EMT arrival

PCR Data Vital Signs

At least two sets should be taken prior to arrival.

PCR Data Patient Narrative Back to Objectives

Chief complaint SAMPLE Objective data Subjective data Pertinent negatives

PCR Data Treatment

Time Effect on patient status

Back to Topics Legal Concerns

Confidentiality Back to Objectives

Information on PCR is confidential Be familiar with HIPAA

Distribution

Follow state rules and local protocol for PCR distribution Leave a copy of PCR at receiving facility (© Ray Kemp/911 Imaging)

Refusal of Treatment

Document competency Document your efforts completely Have patient sign refusal Offer patient alternate methods of getting care Remind patient that EMS can always return

Falsification

Do not try to cover up mistakes Do not compromise patient care

Falsification Correcting Errors

Draw single line, initial it, write the correct information beside it Do not erase Do not write over Back to Objectives

Back to Topics Special Situations

Transfer of Care Report

Obtain a signature from the medical professional who is assuming care Leave a copy of report with facility

Multiple-Casualty Incidents

Follow local MCI plan for record keeping Use triage tags (© Stephanie Ruet/Corbis Sygma)

Special Reports

Suspected abuse Exposures Injuries to EMS members Information for other agencies (© David Handschuh)

Back to Topics Alternative Documentation Methods

SOAP Back to Objectives

S – Subjective O – Objective A – Assessment P – Plan

CHART

C – Chief complaint H – History A – Assessment R – Rx T – Transport

CHEATED

C – Chief complaint H – History E – Exam A – Assessment T – Treatment E – Evaluation D – Disposition

Back to Topics Medical Abbreviations

Only use universally accepted medical abbreviations. Examples: BP – Blood pressure bpm – beats per minute CVA – Cerebrovascular accident CHF – Congestive heart failure Back to Objectives

Follow-Up CASE STUDY

Assessment CASE STUDY You notice he has a bruise above left eye You are able to calm patient He refuses all assessment and treatment

Documentation CASE STUDY You note all pertinent findings Document refusal Have Mr. Makynen read and sign refusal Suggest Mr. Makynen see a doctor or call 911 if things change Now clear and in service

36-year-old female complaining of severe abdominal pain The patient is alert and oriented Vital signs: BP: 88/64 mmHg HR: 128 bpm with weak radial pulses RR: 24 with adequate chest rise Skin is pale, cool, and clammy SpO 2 is 96 percent on room air Critical Thinking Scenario

SAMPLE history: S – Feels light-headed and dizzy every time she stands up; she’s also nauseated A – No known allergies M – Over-the-counter Claritin for allergies P – No pertinent medical history; tonsils removed when she was ten years old L – Nothing to eat or drink for seven hours E – Has “not felt real good” for a few days Critical Thinking Scenario

Pain assessment: O – Pain began suddenly and has progressively worsened; was sitting on the couch watching television when it began P – Nothing makes it better or worse Q – Dull, aching, and intermittent R – Nonradiating S – Eight out of ten T – Four hours Critical Thinking Scenario

Physical exam: Pupils are equal and sluggish to respond Breath sounds are equal and clear bilaterally; no JVD Abdomen is rigid and tender; no evidence of trauma to the abdomen Good motor and sensory function in all four extremities; peripheral pulses are very weak Critical Thinking Scenario

Repeat vital signs: BP: 82/62 mmHg HR: 134 bpm, radial pulses barely palpable RR: 26 with adequate chest rise Skin is more pale, cool, and clammy Pulse oximeter reading “error” Critical Thinking Scenario

En route to the hospital, the patient begins to close her eyes You must verbally instruct her to open her eyes For your PCR documentation: Jennifer Sampson 1321 Oakridge Drive Smithville, Ohio Critical Thinking Scenario

1.What can this information be used for? 2.How will the medical personnel in the medical facility use the information? 3.What will your EMS use the information for? 4.What would you document in the patient information section of the minimum data set? Critical Thinking Questions

5.What would you document in the administrative section of the PCR? 6.What information would you write in the patient narrative section? 7.Should any of the information not be reported in the PCR? 8.If you were to make a mistake while writing the PCR, how would you correct it? Critical Thinking Questions

9.If the PCR contains a box for a third set of vital signs, what would you document in this patient? 10.How would you collect additional information needed for your PCR? Critical Thinking Questions