Charting

The Patient and Family The average person has contact with twice in their lifetime Is it an emergency or not?

How much do you tell them about what’s going on? What about confidentiality?

Radio Communications Why do them? Be concise Use standard format

Radio report should include Unit calling Pt age and gender Name of primary physician Chief complaint General condition Pertinent history Management ETA

Repeat orders back to verify Clarify prn

Report at ED bedside Introduce pt. Use same logical format Include pertinent negatives and positives Include information about allergies and meds

The written record A story –Logical beginning –Logical ending –Bulk of the material in the middle Report must be: –Complete –Accurate –Legible –Left at hospital before clearing call

Written record, cont. Must be signed by both PIC and partner Limit statements to the facts. No assumptions or judgments

Charting, cont. DON’T make discriminatory statements Don’t swear on charts –“get the H**l out of my house” Use quotations Do use accepted abbreviations Draw single line through errors and initial them

Document findings, especially pertinent negatives Will you remember details in 27 years?

Pearls for charting Don’t let your paperwork interfere with patient care If information is not recorded, it was NOT DONE. If you didn’t do it, don’t write it down Don’t document opinions If you forgot it, don’t forget it next time If you ever need it, this is your only defense

Charting formats Flow chart –Fills out the story –Must include baseline vitals, as well as at least one other set –Document times

Medications Critical for DDx Include dosage and dosing regimes for certain meds

Allergies May influence treatment

SOAP format Subjective –Beginning of story Objective –Middle – most difficult part –Document head to toe –General assessment vs focused assessment

SOAP format, cont. Assessment –Or R/O; what do you think is wrong? Plan –What did you do to fix the problem? –What response did the patient have to your tx? –How was the patient physically transferred? –Bed rails up or down? –Whose care did you leave pt in?

Did you? Record all information needed by others? Adequately state all your observations about pt.? Support your clinical impression? List all care given to pt? Use only recognized abbreviations? And your partner sign the form?

And finally… Is your information complete enough so that you could reconstruct the entire situation and defend your actions later if necessary?

CHEATED format Complaint History Exam Assessment Treatment Evaluation Disposition

Refusals Decision-making capacity –The ability to make an informed decision Impaired decision making capacity –The inability to understand the nature of illness or injury, and the risks and consequences of refusing care

Impaired decision making capacity (IDMC) Alcohol ingestion Use of drugs Altered mentation from any medical condition or trauma Don’t use “competent” or incompetent”

IDMC Don’t have impaired person sign refusal form Treat and transport any person who is impaired

Documenting refusals General appearance Vitals H & P Mental status Presence of drugs or alcohol Assessment of decision making capacity Risks explained and advice offered Response to efforts by EMTs to provide care Communications with law enforcement, family, OLMC, pt.

Patient refusal definitions 18 y/o or older No significant mechanism of injury No significant signs of trauma No acute medical condition No behavioral conditions No comorbid factors

Reporting requirements Suspected abuse –Child –Elder –Dog bites

Summary Document to establish a record of care provided Document to protect yourself and agency from questions