4 Documentation During this lesson, students will learn about the roles and responsibilities of an EMT. Advance Preparation Student Readiness Assign the associated section of MyBRADYLab and review student scores. Review the chapter material in the Instructor Resources, which includes Student Handouts, PowerPoint slides, and the MyTest Program. Prepare Make copies of course policies and procedures, the syllabus, handouts from the Instructor Resources, and other materials for distribution or post them in your learning management system. Preview the media resources and Master Teaching Notes in this lesson. Preview the case study presented in the PowerPoint slides and the case study guide in the Instructor Resources. Invite the medical director to the first class session. Make arrangements to tour an emergency department or local PSAP. Obtain 911 recordings to play for the class. Arrange to have an ambulance present at the class location. Bring in a couple of current EMS research articles from a peer-reviewed publication. Ask a health department representative to speak on public health. Plan 100 to 120 minutes for this class as follows: The Emergency Medical Services System: 30 minutes Provides a brief history of EMS system development Describes the current state of EMS and where EMS should be in the future The EMT: 30 minutes Students learn about the characteristics of EMTs, the roles they will play, and the responsibilities of being a health care provider. Research and EMS Care: 20 minutes Describes the concept of evidence-based medicine and the use of research data to improve patient outcomes Public health: 20 minutes Public health is a recent focus for EMS. EMTs can make a difference in public health by participating in health education and illness and injury prevention activities in their communities. The total teaching time recommended is only a guideline. Take into consideration factors such as the pace at which students learn, the size of the class, breaks, and classroom activities. The actual time devoted to teaching objectives is the responsibility of the instructor.

Learning Readiness EMS Education Standards, text p. 56 Explain to students what the National EMS Education Standards are. The National EMS Education Standards communicate the expectations of entry-level EMS providers. As EMTs, students will be expected to be competent in these areas. Acknowledge that the Standards are broad, general statements. Although this lesson addresses the listed competencies, the competencies are often complex and require completion of more than one lesson to accomplish.

Learning Readiness Objectives Please refer to page 56 of your text to view the objectives for this chapter. Objectives are more specific statements of what students should be able to do after completing all reading and activities related to a specific chapter. Remind students they are responsible for the learning objectives and key terms for this chapter.

Learning Readiness Key Terms Please refer to page 56 of your text to view the key terms for this chapter. Assess and reinforce the objectives and key terms using quizzes, handouts from the electronic instructor resources, and workbook pages.

Setting the Stage Overview of Lesson Topics Functions of the prehospital care report (PCR) Collection of data in PCRs Legal concerns Special situations Documentation methods Medical abbreviations

Case Study Introduction EMT Rory Bruns picked up the phone in the Station 4 crew room on the second ring. "EMT Bruns. How can I help you?" Case Study Present the Case Study Introduction provided in the PowerPoint slide set. Lead a discussion using the case study questions provided on the subsequent slide(s). The Case Study with discussion questions continues throughout the PowerPoint presentation. Refer to the Case Study Guide in the Instructor Resources for more information. Case Study Discussion Use the case study content and questions to foreshadow the upcoming lesson content. continued on next slide

Case Study Introduction "It's Dana," replied shift supervisor Dana Hathaway. "I'm afraid I don't have good news. We were served with notice of a subpoena for a patient care report on a call you had last summer. I've pulled a copy of the patient care report. I'll bring it by the station." Case Study Present the Case Study Introduction provided in the PowerPoint slide set. Lead a discussion using the case study questions provided on the subsequent slide(s). The Case Study with discussion questions continues throughout the PowerPoint presentation. Refer to the Case Study Guide in the Instructor Resources for more information. Case Study Discussion Use the case study content and questions to foreshadow the upcoming lesson content.

Case Study How can the PCR help Rory? What kind of information will the parties involved in the legal case be looking for in the PCR? What are some ways to ensure that all important information about each call is documented?

Introduction Documentation of information about EMS calls serves several purposes. The record of care provided is called a patient care report (PCR). Thorough, accurate documentation is a critical EMT skill. Objectives Chapter 4 objectives can be found in an accompanying folder. These objectives, which form the basis of each chapter, were developed from the National EMS Education Standards   Case Study Discussion Use the case study content and questions to foreshadow the upcoming lesson content.

Functions of the PCR Continuity of medical care Administrative uses Legal uses Information for education and research Evaluation and continuous quality improvement (CQI) continued on next slide

Functions of the PCR Continuity of medical care Emergency department (ED) personnel need a record of the patient's prehospital condition and treatment in order to provide the best patient care. Prehospital information about the patient provides a baseline for further evaluation of the patient's condition. Points to Emphasize Thorough, clear documentation of EMS calls serves several important purposes. Information recorded about patients allows emergency department and other health care personnel to develop a more complete understanding of the patient's condition.   Teaching Tips Give examples of calls in which your documentation or that of another EMT has made a difference. continued on next slide

Functions of the PCR Administrative uses Billing and insurance reimbursement Statistical information for future planning Points to Emphasize Administrative uses of the PCR include billing and insurance information to assist with reimbursement for the cost of care and statistics to guide EMS system decision making.   Discussion Question Why is it important that EMS services bill patients and submit insurance claims? continued on next slide

Functions of the PCR Legal uses The patient may be a crime victim or perpetrator whose injuries must be documented. Protection in the event of a civil lawsuit Points to Emphasize Legal actions requiring testimony can take place months or years following a call. It will be impossible to recall all the details of a call after so much time. Good documentation will guide your testimony.   Teaching Tips Ask several students to recall what they ate for breakfast one week ago. Use this to illustrate the difficulty in remembering things that are routine—as EMS calls will one day be for them—even after a short period of time. continued on next slide

Functions of the PCR Education and research PCRs can be a rich source of data to allow research on many issues. PCRs can provide information needed for continuing education planning. Discussion Question How can PCR data be useful in research? continued on next slide

Functions of the PCR CQI CQI is an essential process in all EMS systems. PCRs provide data for comparison against protocols and standards of care. Points to Emphasize Good documentation provides data for research, system evaluation, and continuous quality improvement.   Critical Thinking Discussion What are some reasons EMS documentation may not be as good as it should be? What are some ideas for improving documentation?

Collection of Data in PCRs All documentation must be careful and thorough. There are paper and electronic PCRs. Points to Emphasize PCRs can be paper or electronic in format. Electronic formats can be computer, PDA, or electronic pen-based. The use of written formats may allow a more detailed patient care narrative. Electronic formats can link data, spell-check, and alert users to missing information.   Teaching Tips Provide students with copies of PCRs used locally. If possible, demonstrate an electronic documentation system.

Use standard abbreviations to avoid miscommunication. Beaver Township Fire/EMS, Beaver Township, Ohio: prehospital care report. Points to Emphasize The U.S. Department of Transportation has established a minimum data set for PCRs in an attempt to improve patient care and allow comparisons among EMS services. The components of the minimum data set include patient and administrative information. In general, PCR sections include administrative information, patient demographics and other patient data, vital signs, narrative patient information, and treatment. Use standard abbreviations to avoid miscommunication. Write the narrative in a simple, direct style. Include the patient's chief complaint, medical history, and assessment findings.   Teaching Tips Since students have not yet covered patient assessment and history taking, explain the meaning of each of the components under the Patient Information heading. Discussion Questions What are the purposes of a standard minimum data set? What are some examples of administrative information in the minimum data set? Why are synchronous clocks important in EMS systems?

Use standard abbreviations to avoid miscommunication. Beaver Township Fire/EMS, Beaver Township, Ohio: prehospital care report, continued. Points to Emphasize The U.S. Department of Transportation has established a minimum data set for PCRs in an attempt to improve patient care and allow comparisons among EMS services. The components of the minimum data set include patient and administrative information. In general, PCR sections include administrative information, patient demographics and other patient data, vital signs, narrative patient information, and treatment. Use standard abbreviations to avoid miscommunication. Write the narrative in a simple, direct style. Include the patient's chief complaint, medical history, and assessment findings.   Teaching Tips Since students have not yet covered patient assessment and history taking, explain the meaning of each of the components under the Patient Information heading. Discussion Questions What are the purposes of a standard minimum data set? What are some examples of administrative information in the minimum data set? Why are synchronous clocks important in EMS systems?

Information can be entered on a computerized form from a laptop computer.

A Toughbook computerized PCR form with patient figure on screen.

Collection of Data in PCRs Two basic rules of PCRs If it wasn't written down, it wasn't done. If it wasn't done, don't write it down. continued on next slide

Collection of Data in PCRs Minimum data set Established by the U.S. Department of Transportation (DOT) Collection of standardized information allows meaningful comparison and analysis for the improvement of EMS care, nationally continued on next slide

Collection of Data in PCRs Minimum data set Two parts Patient information Administrative information continued on next slide

Collection of Data in PCRs Patient information Chief complaint Level of responsiveness Blood pressure Skin perfusion Skin color, temperature, condition Pulse rate Respiratory rate and effort Patient demographics continued on next slide

Collection of Data in PCRs Administrative information Time incident was reported Time EMS unit was notified Time of arrival at patient Time unit left the scene Time unit arrived at destination Time care was transferred continued on next slide

Collection of Data in PCRs Accurate, synchronous clocks Dispatch, vehicle, and EMT timekeeping devices must all agree with one another. Needed for accurate documentation of medical care Needed for administrative and legal purposes continued on next slide

Collection of Data in PCRs PCRs usually have these sections: Administrative information Patient demographic and other data Vital signs Patient narrative Treatment continued on next slide

Collection of Data in PCRs Administrative information Information from minimum data set EMS unit number and run or call number Names and levels of certification of crew members Address of call location continued on next slide

Collection of Data in PCRs Patient demographic and other data Information from minimum data set Patient's name, age, sex, race, birth date Patient's home address Insurance and billing information Location patient was found Care given before EMTs' arrival continued on next slide

Collection of Data in PCRs Vital signs Includes minimum data set; EMS systems may require additional information At least two sets of vital signs are needed. Record the patient's position when vitals were obtained. Document the time vitals were obtained. continued on next slide

Collection of Data in PCRs Patient narrative Provide a brief, but thorough picture of the patient and his problem for other medical personnel to use. Includes the chief complaint, patient's history, and physical exam findings. continued on next slide

Collection of Data in PCRs Patient narrative Objective information is verifiable or measurable. Subjective information is based on perceptions or opinions. Pertinent negatives are signs and symptoms that might be expected, but which are not found. continued on next slide

Collection of Data in PCRs Patient narrative Information from the physical exam and pertinent scene information Document the source of information. Use a simple, direct style; no codes or nonstandard abbreviations. Select proper medical terms and spell them correctly. continued on next slide

Collection of Data in PCRs Treatment Detail treatment in chronological order. Document the time of each treatment. Document the patient's response to each treatment.

Match the descriptions on the left with the type of PCR information listed on the right. Click in each box on the left to check your answers. Administrative information Patient demographics Vital signs Narrative Treatment 1. ___ pulse rate 2. ___ EMTs' names 3. ___ "Pt. c/o headache on right side of head for 3 hours." 4. ___ 4 LPM O2 by NC 5. ___ 45 y/o male Click here to continue the program.

Case Study The EMT supervisor, Dana, has just arrived at Station 4 to talk with Rory about the subpoena. As of yet, Rory has not been subpoenaed, but it is possible that he will be. It turns out that it is a criminal case, in which the patient was the victim of domestic violence.

Case Study The county attorney is looking for evidence that might support the case. The defense attorney will try to refute any information that could harm his client. continued on next slide

Case Study What specific elements of the narrative could be important in the prosecution's case? What weaknesses in the documentation will the defense seek to exploit? If Rory is called to testify, what role will the PCR play? continued on next slide

Legal Concerns Legal concerns include: Confidentiality Distribution Refusal of treatment Falsification Correcting errors Points to Emphasize Legal concerns involving PCR documentation include patient confidentiality, distribution of PCR information, documenting refusals of treatment, avoiding falsification of information, and correcting errors. Information on PCRs is considered protected health information (PHI) under HIPAA.   Critical Thinking Discussion How could sharing a patient's protected health information result in harm? continued on next slide

Legal Concerns The PCR contains information that is confidential and which cannot shared with unauthorized individuals. Release of information is governed by HIPAA. continued on next slide

Legal Concerns Specific instances in which PCR information can be distributed include: To health care providers continuing patient care Police, when needed for a criminal investigation Third parties for billing purposes Upon subpoena continued on next slide

Legal Concerns Copies of PCR may be distributed according to state laws and protocols, including: Leaving a copy with the receiving facility A copy retained by the EMS service Copies for medical oversight and CQI continued on next slide

Legal Concerns Legal issues arise when a patient refuses care. Obtain as much information as possible to try to persuade the patient to accept care. Inform patient of consequences of refusing care. Points to Emphasize Situations in which patients refuse treatment require special attention to documenting the fact that the patient understands both the situation and the consequences of refusing care.   Teaching Tips Prior to class, devise a scenario with an assistant so that you can role play obtaining a refusal of treatment for the class. See below under Class Activity. Class Activity Using the role play under Teaching Tips, above, have students document the pertinent information from the refusal. Ask for volunteers to read their documentation aloud. Knowledge Application Give several scenarios of patients refusing care. Ask the class for ideas on handling each situation. continued on next slide

Legal Concerns Determine patient's competence to refuse care. Contact medical direction as needed Document the following information: Your assessment findings Any emergency care you provided Your explanation of the consequences of refusing care continued on next slide

Legal Concerns Document the following information: If the patient refused any or all components of assessment and the treatment offered The patient's mental status, to establish that he was competent to make the decision to refuse care continued on next slide

Legal Concerns Have the patient, and if possible, a witness sign the refusal form. If the patient refuses to sign, obtain a signature from a witness who can verify the refusal. Complete all sections of the refusal form. continued on next slide

Beaver Township Fire/EMS, Beaver Township, Ohio: patient refusal section on prehospital report.

Legal Concerns When a patient refuses care, advise him of alternative ways to obtain transportation and care. Explain signs and symptoms that could indicate his condition is worsening. Explain that if the patient changes his mind, he can call 911 at any time. continued on next slide

Legal Concerns PCRs must be thorough and accurate. Mistakes or omissions in care must be documented accurately. Never provide false information in a PCR. Points to Emphasize Regardless of the reason the EMT may be tempted, it is critical that PCR information never be falsified. Always use acceptable methods of correcting errors on the PCR.   Discussion Questions What are the consequences to a patient of falsifying documentation? You have inadvertently written that a patient is 58 years old, instead of 68 years old. What is the acceptable way of correcting this on a written PCR? continued on next slide

Legal Concerns Falsification of PCR information can lead to loss of licensure and, possibly, criminal charges. Falsification compromises patient care. continued on next slide

Legal Concerns To correct errors in documentation Draw a single line through the mistake. Provide the correct information. Initial and write the date and time of the correction.

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

Special Situations Transfer of care When it is not possible to complete the PCR and obtain a signature from the person accepting patient care before leaving the facility, a special transfer-of-care form may be used. Points to Emphasize If it is not possible to leave a complete PCR, an abbreviated transfer of care report will help maintain continuity of care.   Teaching Tips Show students any special reporting forms used locally. continued on next slide

Special Situations Multiple-casualty incidents Demands of the situation may not allow completion of PCRs. Triage tags can be used to communicate basic patient information. Points to Emphasize You may use an abbreviated form or triage tag to record essential patient information in multiple-casualty incidents. continued on next slide

Special Situations Special reports may be required for: Suspected child or elder abuse Possible infectious disease exposure Injury to the EMS provider Situations requiring additional documentation or notification of other agencies Follow state laws and protocols for special reports. Points to Emphasize State laws and system protocols may require other types of documentation. Examples include EMS team member injuries and suspected cases of abuse.   Discussion Question Why is it important that some events be recorded separately from the PCR?

Alternative Documentation Methods Several formats for narrative documentation are represented by mnemonics. SOAP CHART CHEATED continued on next slide

Alternative Documentation Methods SOAP Subjective Objective Assessment Plan continued on next slide

Alternative Documentation Methods SOAP Subjective information is what the patient tells you. Includes symptoms Points to Emphasize EMS systems may or may not require a specific format for the PCR narrative. The SOAP format is often used in nursing and by other health care professionals.   Teaching Tips If not handed out previously, hand out a photocopied fictitious PCR and explain the method used to format the narrative. Explain that this introduction of documentation is necessary to structure students' thinking about collecting information, but that they will increase their understanding of documentation throughout the course. continued on next slide

Alternative Documentation Methods SOAP Objective information consists of signs you can detect with your senses. Includes the observations made in the physical exam continued on next slide

Alternative Documentation Methods SOAP Assessment is your impression of the patient based on evaluation of the subjective and objective information. continued on next slide

Alternative Documentation Methods SOAP Plan refers to the treatment provided. continued on next slide

Alternative Documentation Methods SOAPIE is a variation of SOAP that includes Intervention and Evaluation. continued on next slide

Alternative Documentation Methods CHART Chief complaint History Assessment Rx (treatment) Transport Discussion Questions What are advantages and possible disadvantages of each of the methods of documentation? How can mnemonics such as these be helpful in documentation? continued on next slide

Alternative Documentation Methods CHART Chief complaint is what the patient says is the reason for seeking medical care. continued on next slide

Alternative Documentation Methods CHART History includes the SAMPLE history Symptoms Allergies Medications Past medical history Last oral intake Events leading to the problem continued on next slide

Alternative Documentation Methods CHART Assessment includes findings from the primary and secondary assessments, detailed physical exam, and ongoing assessment. continued on next slide

Alternative Documentation Methods CHART Rx (treatment) includes all interventions provided. continued on next slide

Alternative Documentation Methods CHART Transport describes how the patient was transported and any changes in his condition during transport. continued on next slide

Alternative Documentation Methods CHEATED Chief complaint History Exam Assessment Treatment Evaluation Disposition Knowledge Application Select one of the documentation methods covered. Call out various pieces of information for a PCR narrative in random order. Have students identify where in the narrative each piece of information fits.

Medical Abbreviations Save time and space in documentation. Use only universally accepted abbreviations. Points to Emphasize It is critical that EMTs use only standard charting abbreviations.   Teaching Tips Review Table 4-2 with students. Call out a category or type of patient information and ask students for the abbreviation. Discussion Question What are advantages and possible disadvantages of medical abbreviations? Class Activity Divide students into teams. Give each team a bell to ring. Write a medical abbreviation on the board. The first team to ring their bell answers. If they answer correctly, the team gets 5 points. If they answer incorrectly, the other team gets an opportunity to answer. Knowledge Application As class proceeds, have students write PCRs for their lab scenarios using standard abbreviations.

Case Study Conclusion Rory was eventually called to testify at the trial of the accused perpetrator. Fortunately, because the case occurred a year after the call, Rory was able to rely on his thorough and accurate documentation to answer the attorneys' questions about his observations of the scene and the patient's condition. continued on next slide

Case Study Conclusion The defense attorney questioned the meaning of several of the abbreviations Rory used in the PCR. Because Rory always uses standard, accepted abbreviations, the defense attorney was unsuccessful in discrediting his documentation. Nonetheless, it is an experience Rory hopes he doesn't have to repeat.

Lesson Summary PCRs serve several purposes. Continuity of medical care Administrative uses Legal uses Education and research Evaluation and CQI Class Activity As an alternative to assigning the follow-up exercises in the lesson plan as homework, assign each question to a small group of students for in-class discussion.   Teaching Tips Answers to In Review questions are in the appendix of the text. Advise students to review the questions again as they study the chapter. Follow-Up Answer student questions. Follow-Up Assignments Review Chapter 4 Summary. Complete Chapter 4 Critical Thinking questions. Assessments Handouts Chapter 4 quiz continued on next slide

Lesson Summary Characteristics of good documentation Thorough and accurate Contains acceptable objective and pertinent subjective information Is legible continued on next slide

Lesson Summary Thoroughly document refusals of care. Never falsify PCR information. Correct PCR errors properly.