Division 2 Patient Assessment Bledsoe et al., Essentials of Paramedic Care: Division 1I © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Chapter 15 Documentation Bledsoe et al., Essentials of Paramedic Care: Division 1I © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Topics Principles and Purposes of EMS Documentation Medical Terminology and Abbreviations Roles of Documentation Subjective and Objective Documentation Evaluation of a Finished Document Special Situations Bledsoe et al., Essentials of Paramedic Care: Division 1I © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Importance of Documentation Provides for the following: A written record of the incident A legal record of the incident Professionalism Medical audit Quality improvement Billing and administration Data collection Bledsoe et al., Essentials of Paramedic Care: Division 1I © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

“The content and completeness of the pre-hospital care report directly affects the lawyer’s impression of the incident and influences his decision of whether or not to file a lawsuit.” Richard A. Lazar, JD Bledsoe et al., Essentials of Paramedic Care: Division 1I © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Written Record of Incident May be the only source of information for persons subsequently interested in the event Record of the incident from beginning to end Provides a source of identifying pertinent reportable clinical data from each patient reaction Bledsoe et al., Essentials of Paramedic Care: Division 1I © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Introduction Your written prehospital care report (PCR) is the only true factual record of events. Your PCR is your sole permanent, complete written record of events during the ambulance call. Bledsoe et al., Essentials of Paramedic Care: Division 1I © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Uses for PCRs Medical Administrative Research Legal Bledsoe et al., Essentials of Paramedic Care: Division 1I © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

agencies to improve patient care. Run data in a PCR helps agencies to improve patient care. Bledsoe et al., Essentials of Paramedic Care: Division 1I © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Complete both the narrative and check-box sections of every PCR. Bledsoe et al., Essentials of Paramedic Care: Division 1I © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

General Considerations The Prehospital Care Report should be carefully detailed and legible. It is viewed as a legal document and is part of the patient’s medical record. Use of slang terminology or medical abbreviations that are not universally accepted should be avoided. If you do not know how to spell a word, look it up or use another word. Bledsoe et al., Essentials of Paramedic Care: Division 1I © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Some systems use check boxes, some use bubble sheets, and others use electronic documentation. © Jeff Forster Bledsoe et al., Essentials of Paramedic Care: Division 1I © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Times Whenever possible, record all times from the same clock. When that is not possible, be sure that all the clocks and watches you use are synchronized. Bledsoe et al., Essentials of Paramedic Care: Division 1I © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Communications Communications with the hospital are another important item to document. Document ANY medical advice or orders you receive and the results of implementing that advice and those orders. Bledsoe et al., Essentials of Paramedic Care: Division 1I © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Pertinent Negatives Document all findings of your assessment, even those that are normal. Pertinent negative findings may help determine the course of treatment and should be recorded. Pertinent negative findings are those that warrant no medical care or intervention, but which, when the paramedic seeks them, show evidence of the thoroughness of his or her examination and history of the event. Bledsoe et al., Essentials of Paramedic Care: Division 1I © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Oral Statements Whenever possible, quote the patient—or other source of information—directly. Example: Bystanders state the patient was “acting bizarre and threatening to jump in front of the next passing car.” Record statements that may have an impact on subsequent patient care or resolution of the situation: Mechanism of injury Patient’s behavior First-aid interventions attempted before arrival of EMS personnel Safety‑related information, including disposition of weapons Information of interest to crime scene investigators Disposition of valuable personal property (e.g., watches, wallets) Bledsoe et al., Essentials of Paramedic Care: Division 1I © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Elements of Good Documentation Accuracy Legibility Timeliness Unaltered Professionalism Completeness Accuracy – All information must be precise and comprehensive. Legibility – Document must be able to be read by others without difficulty. Timeliness – Complete and submit all reports in a timely fashion so that details surrounding the incident are clear and well articulated in the PCR. Unaltered – Never alter a medical record after it has been submitted. Have your documentation reviewed by your partner prior to submission. Professionalism – Use correct grammar and spelling. Write legibly and use only universally accepted abbreviations; avoid abbreviations that are only utilized in your service or a specific geographic region. Completeness – Any field within the report left blank is considered to be either not completed or not assessed. If there are check boxes, and they do not relate to the patient, strike through the field or write N/A throughout the entire field. Bledsoe et al., Essentials of Paramedic Care: Division 1I © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Make certain that your documentation is consistent with the detail and clarity that would be provided by other paramedics in different parts of the country. Bledsoe et al., Essentials of Paramedic Care: Division 1I © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

The Proper Way to Correct a Prehospital Care Report Bledsoe et al., Essentials of Paramedic Care: Division 1I © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

One Example of a “Refusal of Care” Form Bledsoe et al., Essentials of Paramedic Care: Division 1I © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Professionalism Never include slang, biased statements, or irrelevant opinions. Include only objective information. Always write and speak clearly. Bledsoe et al., Essentials of Paramedic Care: Division 1I © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Narrative Writing Subjective part of your narrative comprises any information you elicit during your patient’s history. Objective part of your narrative usually includes your general impression and any data you derive through inspection, palpation, auscultation, percussion, and diagnostic testing. Bledsoe et al., Essentials of Paramedic Care: Division 1I © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Narrative (1 of 2) Narrative portion of the PCR allows for a chronological description of the call. It should be carefully detailed and legible. Bledsoe et al., Essentials of Paramedic Care: Division 1I © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Narrative (2 of 2) The PCR is a legal document and part of the patient’s medical record. Use of slang or medical abbreviations that are not universally accepted should be avoided. Bledsoe et al., Essentials of Paramedic Care: Division 1I © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Two Narrative Formats CHART SOAP Chief complaint History Assessment Rx (treatment) Transport SOAP Subjective Objective Assessment Plan Bledsoe et al., Essentials of Paramedic Care: Division 1I © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Documentation Revisions When: as soon as the need for revision is identified. Date and time of revision must be documented. Who: always made by the original author of the document being revised. How: written on a separate, supplemental report form. Bledsoe et al., Essentials of Paramedic Care: Division 1I © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Special Considerations Patient refusals Services not needed Deviations from the standard Mass-casualty incidents Bledsoe et al., Essentials of Paramedic Care: Division 1I © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Patient Refusals Patients retain the right to refuse treatment or transportation if they are competent to make that decision. Two main types of refusals: Person who is not seriously injured and does not want to go to the hospital. The patient refuses even though you feel he needs it. Bledsoe et al., Essentials of Paramedic Care: Division 1I © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

A patient’s refusal of care requires careful documentation. Bledsoe et al., Essentials of Paramedic Care: Division 1I © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Services Not Needed Some systems allow paramedics to determine patients that do not require ambulance transportation. While this may help to reduce ambulance utilization, the risks of denying transport are even greater than those of a refusal. Evaluate all patients with even minor injuries and document appropriately. Bledsoe et al., Essentials of Paramedic Care: Division 1I © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Mass-Casualty Incidents Multiple patients, mass casualties, and disasters all present special documentation problems. Weigh your patient’s needs against the demand for complete documentation. Follow local guidelines and utilize the appropriate forms such as triage tags. Bledsoe et al., Essentials of Paramedic Care: Division 1I © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Triage tags are used to record vital information on each patient quickly. Bledsoe et al., Essentials of Paramedic Care: Division 1I © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Consequences of Inappropriate Documentation (1 of 2) Inappropriate documentation can have both medical and legal consequences. Do not guess about your patient’s problems. Write neatly, clearly, and legibly. Complete your form completely. Spelling counts! Bledsoe et al., Essentials of Paramedic Care: Division 1I © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Consequences of Inappropriate Documentation (2 of 2) Primary caregiver is responsible for charting the run report (if you are in the back of the ambulance taking care of the patient, you write the report). Prior to releasing subpoenaed information, the requested documents should be reviewed by an attorney to determine if a supplemental report should be created. Bledsoe et al., Essentials of Paramedic Care: Division 1I © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Summary Principles and Purposes of EMS Documentation Medical Terminology and Abbreviations Roles of Documentation Subjective and Objective Documentation Evaluation of a Finished Document Special Situations Bledsoe et al., Essentials of Paramedic Care: Division 1I © 2006 by Pearson Education, Inc. Upper Saddle River, NJ