10 Documentation

Multimedia Directory Slide 33 Explaining Medical Terminology Video

Standard Preparatory (Documentation)

Competency Integrates comprehensive knowledge of EMS systems, the safety and well-being of the paramedic, and medical/legal and ethical issues, which is intended to improve the health of EMS personnel, patients, and the community.

Introduction Prehospital care report (PCR): factual record of events that occur during EMS call or other patient contact. Describes assessment and care throughout emergency call Documents exactly what you did, when you did it, effects of interventions Sole permanent, complete written record

Introduction PCR Three Major Goals To provide information to subsequent health care professionals about patient and treatments provided in prehospital setting To provide essential information for proper billing of patient To provide legal record of the call's circumstances

Uses for Documentation Medical PCR can tell emergency department staff of patient's condition before arrival at hospital. Baseline for comparing assessment findings and detecting trends that indicate improvement or deterioration

Uses for Documentation Medical Surgical staff: MOI and other findings during primary assessment. Floor or intensive care unit staff: information about original condition. Information from people at scene; circumstances that led to event or MOI

The run data in a prehospital care report is vital to your agency's efforts to improve patient care.

Uses for Documentation Administrative Gather information for quality improvement and system management. Response times Call location Use of lights and siren Date and time

Uses for Documentation Research Analyze recorded data to determine efficacy of medical devices or interventions. Use data to cut costs, alter staffing, shorten response times. Some systems use computerized or electronic PCRs and computerized database to analyze data.

The handheld electronic clipboard enables you to enter your prehospital care report directly into a computer. (© Kevin Link)

Uses for Documentation Legal PCR permanent part of patient's medical record. Lawyers may refer to it when preparing court actions. In legal proceeding, it might be sole source of information about the case. May serve as evidence in criminal case

Uses for Documentation Legal Always write PCR as if you will have to refer to it someday in court proceeding. Describe patient's condition when you arrived and during care, status on arrival at hospital. Document condition before and after any interventions. Avoid writing subjective opinions. Points to Emphasize Remind the students to write every run report as if they will have to explain it in five years in the future to a room full of people.

General Considerations Every EMS system has its own specific requirements for documentation. Reports with check boxes Bubble sheets Computerized documentation

General Considerations Medical Terminology Use appropriate medical terminology. Abbreviations and Acronyms Use correct abbreviations and acronyms. Formed from initial letters of words they stand for Class Activities As a group, go over as many abbreviations and acronyms as can be thought of, along with the EMS meaning.

Standard Charting Abbreviations

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Explaining Medical Terminology Video Questions: Why is it important for paramedics to use appropriate medical terms? Why is it important to understand prefixes, suffixes, roots, and stems when developing a medical vocabulary? How can paramedics effectively implement their medical terminology?   Click here to view a video on the topic of medical terminology. Back to Directory

General Considerations Times Times you record on PCR considered official times of incident. For medical and legal purposes, ensure their accuracy.

General Considerations Times Time call received Dispatch time Time of arrival at scene Time of departure from scene Time of arrival at hospital Time back in service Record all times from same clock.

General Considerations Communications PCR likely only permanent record of your discussion with medical direction physician. Document medical advice or orders you receive and results of implementing. Document what you reported to physician and/or discussed. Document physician's name.

General Considerations Pertinent Negatives Document all findings of assessment, even those that are normal. Negative findings; vary for each chief complaint Points to Emphasize Discuss the importance of pertinent negatives, and how these negative statements reflect a thorough patient assessment. Knowledge Application Assign for homework a short number of medical complaints (e.g., shortness of breath, chest pain, headache) and have the students write out the pertinent negatives they would ask to rule out other problems.

General Considerations Oral Statements Statements of witnesses, bystanders, patient Document MOI, patient's behavior, events leading up to emergency, first aid or medical care others rendered before you arrived At crime scenes, document safety-related information.

General Considerations Additional Resources Document all resources involved in event: Air-medical service EMS, fire, rescue/extrication Law enforcement agencies Physicians/medical direction physicians Document integration carefully.

Elements of Good Documentation Completeness and Accuracy Accurate PCR: precise but comprehensive. Include all relevant information; exclude superfluous information. Complete both narrative and check-box sections. Narrative core of the documentation

Elements of Good Documentation Completeness and Accuracy Make sure information in checked boxes and narrative is consistent. Use proper spelling, approved abbreviations, proper acronyms.

Elements of Good Documentation Legibility Poor penmanship and illegible reports lead to poor documentation. Handwriting must be neat. Other members of health care team may use report for medical information, research, or quality improvement.

Elements of Good Documentation Timeliness Avoid writing report in ambulance during transport of patient. Complete paperwork once patient care is transferred. Complete report immediately after emergency call.

Elements of Good Documentation Absence of Alterations If you make a mistake writing your report, simply cross through error with one line and initial it. Do not scribble over or blacken out any area of call report. Never try to hide an error. If you find error after you've written several sentences, submit addendum. Class Activities Walk the students through writing a run report, showing examples of how to line out an error and nothing the importance of correct grammar and spelling, legible handwriting, etc.

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

Elements of Good Documentation Absence of Alterations Whenever possible, have everyone involved in call read or reread PCR. Make corrections before you submit report. Write any addendum to your report as soon as you realize that you made error or that additional information needed.

Elements of Good Documentation Professionalism Write report in professional manner. Write cautiously; avoid remarks that might be construed as derogatory. Avoid jargon, slang, biased statements, irrelevant opinions. Write and speak carefully.

Narrative Writing Narrative depicts call at length. Describes assessment findings in detail Narrative Sections Subjective narrative Objective narrative Assessment/management plan

Narrative Writing Subjective Narrative Information elicited during patient's history: Chief complaint (CC) History of present illness (HPI) Past history (PH) Current health status (CHS) Review of systems (ROS) Mechanism of injury (MOI)

Narrative Writing Objective Narrative General impression; data through inspection, palpation, auscultation, percussion, diagnostic testing: Vital signs Physical exam Tests

Narrative Writing Objective Narrative Head-to-toe approach: well suited for any call when you perform entire physical exam. Encourages you to be systematic and thorough Appropriate for major trauma and serious medical emergencies

Narrative Writing Objective Narrative Body systems approach: focuses on body systems instead of body areas. Suited to screening/preadmission exams In emergency medicine, focus only on system(s) involved in current illness or injury. One of the most comprehensive approaches to documentation

Narrative Writing Assessment/Management Plan Document what you believe to be patient's problem. Field diagnosis (impression) Rule out identifies diagnoses you believe emergency physician should evaluate. Record complete management plan from start to finish.

Narrative Writing General Formats SOAP Format S = Subjective O = Objective A = Assessment P = Plan

Narrative Writing General Formats CHART Format C = Chief complaint H = History A = Assessment R = Rx (treatment) T = Transport Knowledge Application Give the students a scenario and have them write out a narrative based on the SOAP and CHART formats.

Narrative Writing General Formats Patient Management Preferred for some critical patients Focus on managing variety of patient problems; not on conducting thorough history and physical exam. Chronological account Assessment and management of conditions

Narrative Writing General Formats Call Incident Approach Emphasizes MOI, surrounding circumstances, how incident occurred. Documenting trauma call with significant MOI Suitable when events surrounding call might be significant. Discussion Topics Go over the four formats listed that aid in writing the narrative.

Special Considerations Patient Refusals Person not seriously ill or injured; does not want to go to hospital Patient signs PCR “Refusal of Care,” and you return to service. Patient refuses care even though he needs it; against medical advice (AMA). Patients retain right to refuse treatment or transportation if competent.

Special Considerations Patient Refusals Document that you believe patient was competent to refuse care. Document patient has adequate mental status and understands field diagnosis, alternative treatments, consequences of refusing care. Record reason for refusing care.

Refusal of Care Documentation Checklist

Special Considerations Patient Refusals Inform of potential complications from injuries that might not be obvious. Document any involvement of patient's family or friends. May need to make clear possibility of patient's dying.

Special Considerations Patient Refusals In many systems, you must contact medical direction physician before allowing patient to refuse transport. Note that you instructed him to call ambulance or go to emergency department if condition worsens. Include narrative with quotations and statements from others on scene.

Special Considerations Services Not Needed Document transport was unnecessary. Document any discussion you have with emergency physician. If ambulance canceled en route, document canceling authority and time of notification. Document if you arrive on scene and find no patients.

Special Considerations Multiple Casualty Incidents Multiple patients, mass casualties, and disasters have special documentation problems. Weigh patients' needs against demand for complete documentation. Document as much as possible, as quickly as possible, on PCR.

Special Considerations Multiple Casualty Incidents Complete documentation later as addendum. Document only what you know to be factual and accurate. Be familiar with local policies and procedures for documenting these situations.

Special Considerations Multiple Casualty Incidents Triage tag: patient's vital information—name, major injuries, vital signs, treatment, priority (urgent, nonurgent). Affix it to patient; remains there throughout event Transfer its information to PCR later.

Consequences of Inappropriate Documentation Medical Consequences Potentially most serious Can affect patient care for hours/days after ambulance call ends Good documentation now enables good care later. Critical Thinking Questions What would happen if you had a patient in cardiac arrest, your documentation was inappropriate, and the patient later died and the family brought a lawsuit against you for inadequate care? Could you be held liable for negligence, even if you knew you did the care but did not document it?

Consequences of Inappropriate Documentation Legal Consequences Poor, incomplete, inaccurate documentation encourages anyone who is pursuing frivolous lawsuit. Good documentation discourages such actions. Remember: if it is not documented, you did not do it. Points to Emphasize If you didn't write it down, you didn't do it.

Electronic Patient Care Records Benefits of Electronic PCR Systems Greater ease of data collection and analysis Consistent, uniform, easily read patient chart Reduction of poor penmanship and spelling errors Opportunity for EMS administrator to configure and alter the software.

Electronic Patient Care Records Benefits of Electronic PCR Systems Integration with dispatch software, billing services, regulatory agencies Interface with medical devices Better quality assurance processes, chart reviews, feedback to EMT or paramedic

Electronic Patient Care Records Benefits of Electronic PCR Systems Data “pick from” list: values presented and EMT selects item or items from list. Graphic interface Manual entry Teaching Tip Obtain an electronic clipboard for the students to view.

A graphic interface on ePCR. (© Zoll Medical Corporation)

Electronic Patient Care Records Drawbacks of Electronic PCR Systems Prohibitive cost Fees for technical support, upgrades, support from software vendor Requires personnel to administer and deal with day-to-day issues Institutional reluctance; push-back from field crews

Closing As paramedic you will assume responsibility for your documentation. It is one of the most important parts of EMS call. Ensuring documentation is complete, accurate, legible, appropriate is one of your professional responsibilities.

Closing Your report's confidentiality cannot be overemphasized. Confidentiality is patient's legal right. Electronic charting will become common in the future; effective documentation still applies.

Summary All EMS records should possess same basic attributes. Appropriate terminology, proper spelling, accepted abbreviations and acronyms, accurate times are essential.

Summary Description of assessment and interventions (pertinent negatives and communications with on-line physicians) important. All personnel and resources involved in call must be documented. Record must be accurate and precise, free of jargon, neatly written.

Summary Corrections made properly, including use of addendum when appropriate. Systems of documentation: CHART and SOAP formats; use one consistently. Special situations (multiple patients and refusals of transportation) require extra attention.

Summary Complete narrative and check boxes best way to ensure necessary information is documented. Documentation one of the most important parts of EMS call. Permanent record of ambulance call.