8 Principles of Effective Documentation

Objectives Define the following terms: Continuity of care Electronic documentation Minimum data set Patient Care Report (PCR) Explain the purpose of the patient care report. Describe the elements of a typical patient care report. continued on next slide

Objectives Describe the minimum data set required for the documentation of patient care. Explain the procedure for correcting errors made during documentation. List various tools used to document patient care in the field setting. continued on next slide

Objectives Demonstrate the ability to accurately document a simulated patient encounter. Properly correct an error made during documentation. Value the importance of complete and accurate documentation.

Topics Patient Care Reports Methods of Documentation

PATIENT CARE REPORTS

Patient Care Reports Documentation is a permanent record of provided care. Reports may be handwritten or electronic and recognized by different titles. Run reports Patient care reports Prehospital care reports Discussion Question: Why should you create accurate and detailed documentation?

Figure 8.1 Example of a typical paper-style patient care report (PCR) form.

Figure 8.2 Electronic documentation of an emergency call is becoming more common.

Patient Care Reports Reasons for accurate and complete documentation Continuity of care Education Administration Quality assurance Legal Discussion Question: How can PCRs be made more accurate? What are some potential barriers?

Patient Care Reports Elements of the PCR Sections of the Report Run data Information about call Patient data Patient information Sections of the Report Fill-in Check boxes Narrative Teaching Tip: Require documentation following all in-class simulated calls. Create a QI group to conduct peer review (change this group weekly so every student gains the experience).

Patient Care Reports Information in narrative should be objective rather than subjective. Objective Straightforward facts Subjective Up for interpretation May include descriptions Class Activity: Provide a sample scenario patient simulation for an emergency call involving an unresponsive trauma victim with no witnesses and a high suspicion of assault Direct students to write a narrative based on what they encountered from beginning to end; being careful to document objectively rather than subjectively. Share narratives and discuss. (Consider having a teaching assistant or volunteer in moulage, placed in a room where there appears to have been a struggle. Ensure that students document only what they see, not what they assume).

Patient Care Reports Minimum Data Set Time incident was reported to 911 Time of dispatch Time of arrival at patient's location Time patient was transported from incident location Time patient arrived at destination (e.g., hospital, aid station) Discussion Question: Why is data collection so important? continued on next slide

Patient Care Reports Minimum Data Set Time patient care was transferred to more advanced providers Patient's chief complaint Patient's vital signs Patient's demographics Age, gender, race, weight Discussion Question: When would it be important to include more information than is required for a minimum data set?

Patient Care Reports Correcting Errors Cross out incorrect item with single line, initial it, write correct number beside or above it. Never completely cover incorrect information. It may appear you are attempting to hide something. Discussion Question: What types of errors on a PCR might be acceptable to correct? When might it not be acceptable to correct a PCR?

Figure 8.3 An example of how to properly document an error in documentation.

Think About It The quality of your documentation is reflective of the care you provide. How can data collection benefit EMS? What elements would be essential to document for a refusal of care?

METHODS OF DOCUMENTATION

Methods of Documentation Paper forms PCR forms filled out by hand Computer-scan forms PCR forms completed by hand Fill-in-the-bubble format can be scanned into computer for information management and statistics gathering. Talking Point: Electronic PCR is widespread. The EMR needs to be familiar with the different electronic documentation hardware and software available.

Methods of Documentation PDAs or handheld computers Specialized software allows emergency care professionals to enter PCR information. Information then downloaded to computer devices at hospital, base, or main office Discussion Question: How might electronic PCRs be beneficial? Why might a paper PCR be preferred?

Methods of Documentation Laptop computers Software allows responders to complete PCR on computer and print from docking station or send wirelessly to hospital or central database. Class Activity: If the technology is available, allow students to complete a sample PCR based on a provided scenario using electronic PCR software.

Figure 8.4 A typical electronic tablet used for documenting patient care.

Methods of Documentation Data-enabled cellular devices Advanced cellular data devices operate PCR applications to complete and send documentation quickly and easily from cellular phones.

Think About It How might electronic PCR be useful during an emergency with multiple patients? What legal circumstances might require review of a PCR? Talking Point: Believe it or not, hospital staff read PCRs! Sometimes PCRs are read days after the emergency when the patient is an inpatient and a physician wants more details about what occurred prior to admission. Do not underestimate the value of documentation!

SUMMARY

Summary Patient care documentation is important. Continuity of medical care to legal proceedings Becomes permanent part of patient's medical record Can be used by EMS organizations to improve overall quality of emergency services continued on next slide

Summary PCR main categories Run data Patient data Completed using combination of fill-ins, check boxes, and narrative areas continued on next slide

Summary Each PCR has a minimum data set as defined by U.S. Department of Transportation. Documentation errors should be corrected without trying to obscure erroneous information. Put a single line through mistake, enter correct information above or beside it, initial change. continued on next slide

Summary Patient care documentation completed Traditional paper-based forms High-tech handheld computers Data-enabled cellular devices Ensure accuracy and avoid subjectivity when documenting what happened on each response.

REVIEW QUESTIONS

Review Questions What is the purpose of the PCR? What elements are typically included in the PCR? What are the tools used to complete documentation in the field?

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