Slide 1 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Documentation Chapter 15

Slide 2 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Case History You have been working as an EMT-Basic for 6 years. Your supervisor informs you that you are to testify in a lawsuit the day after tomorrow. The lawsuit pertains to an ambulance call you had 4 years ago. Not remembering the call very well, you look at the prehospital care report (PCR) to refresh your memory. You find that the PCR is incomplete and illegible. You have been working as an EMT-Basic for 6 years. Your supervisor informs you that you are to testify in a lawsuit the day after tomorrow. The lawsuit pertains to an ambulance call you had 4 years ago. Not remembering the call very well, you look at the prehospital care report (PCR) to refresh your memory. You find that the PCR is incomplete and illegible.

Slide 3 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Documentation  Minimum data set  National standard for essential documentation  Critical for EMT to document action clearly  Best legal defense  Important to patient care

Slide 4 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Functions of a Prehospital Care Report  Continuity of care  Legal document  Good report  Times  Assessment findings  Patient care  Changes on arrival at the receiving facility

Slide 5 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Functions of a Prehospital Care Report  Educational  Administrative  Billing  Service statistics  Research  Evaluation and continuous quality improvement

Slide 6 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Continuous Quality Improvement  Used to analyze various aspects of the EMS system  Used to improve different components of the system  Prevents problems from occurring

Slide 7 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Administrative Information  Time incident reported  Time unit notified  Time of arrival at patient

Slide 8 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Administrative Information  Time unit left scene  Time of arrival at destination  Time of transfer of care  Patient disposition information

Slide 9 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Principles of Record Keeping  Accuracy and honesty  Clarity  Completeness  Chronology and trends (see below)

Slide 10 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Sections of a Prehospital Care Report  Run data  Date, times, service, unit, names of crew  Patient data  Patient name, address, date of birth  Insurance information  Sex, age, nature of call, mechanism of injury  Location of patient

Slide 11 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Sections of a Prehospital Care Report  Patient data  Treatment administered before arrival of EMT  Signs and symptoms  Care administered, baseline vital signs  SAMPLE history  Changes in condition

Slide 12 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Narrative Section  Describe, don't conclude.  Include pertinent negative findings.  Record important observations about the scene (e.g., suicide note, weapon).  Avoid radio codes.  Spell words correctly.  Use standard abbreviations.

Slide 13 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Narrative Section  Information of a sensitive nature (e.g., communicable diseases)  Note the source.  State reporting requirements  For every reassessment, record time and findings  Other state or local requirements

Slide 14 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Types of Reports  Written  Check boxes  Section for narrative  Computerized  Information entered onto electronic clipboard

Slide 15 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Patient Data  Chief complaint  Level of consciousness  AVPU  Systolic blood pressure for patients > 3 years old  Skin perfusion  Capillary refill for patients < 6 years old

Slide 16 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Patient Data  Skin color and temperature  Pulse rate  Respiratory rate and effort

Slide 17 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Patient Refusal  Complete report.  Complete patient assessment.  Note care EMT wished to provide  Statement that EMT explained  Possible consequences  Including potential death  Offer alternative methods of gaining care.  State willingness to return.

Slide 18 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Documentation of Patient Refusal  Competent adults have the right to refuse treatment.  Ensure patient is able to make an informed decision.  No alcohol or other drugs  No impaired judgment  Inform the patient  Why he or she should go to the hospital  What may happen if he or she does not go  Consult medical direction, as directed by local protocol.

Slide 19 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Special Situation Reports  Used to document events reported to local authorities  Amplify and supplement primary report  Should be accurate and objective  Should be submitted in timely manner  EMT should keep a copy  Follow local protocol

Slide 20 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Special Situation Reports  Documentation of death  Emotionally disturbed, underage, or unconscious patients  Dying statements  Homicide and suicide

Slide 21 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Falsification Issues  Never cover up an error or omission.  Document what did or did not happen.  Steps that were taken (if any) to correct the situation  Falsification  May lead to suspension or revocation of certification/license  Poor patient care

Slide 22 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Areas of Difficulty  Vital signs  Document only the vital signs that were actually taken.  Treatment  If a treatment (such as oxygen) was overlooked, do not chart that the patient was given oxygen.

Slide 23 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Correction of Errors  General rules  Cross out error.  Enter corrected data.  Initial next to correction.  Errors that are recorded at a later time Use different colored ink. Use different colored ink. Include the date. Include the date.

Slide 24 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Triage Tags   Timesaving method   Used in MCIs   Focus on the essentials of care   Establishes priority of patients

Slide 25 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Documenting Death  Death should be documented by recording physical finding such as  Decomposition  Extreme dependent lividity  Rigor mortis  Obvious lethal injuries (e.g., decapitation) “Patient found facedown in bed with rigor mortis and extreme dependent lividity on the anterior surface of the body.”

Slide 26 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Confidentiality  PCR is considered confidential.  Be familiar with state laws.  Distribution  Follow local and state protocol and procedures