1. Chapter 4 Documentation Copyright ©2010 by Pearson Education, Inc. All rights reserved. Prehospital Emergency Care, Ninth Edition Joseph J. Mistovich Keith J. Karren

2. CASE STUDY Dispatch

3. EMS Unit 17 Respond to 57 Vallejo Road for a vehicle versus a parked car Time out 1321

4. Upon Arrival Female party who called 911 indicates the male who struck her vehicle was slumped over wheel States now he seems okay As you approach a mid-30s male he states, “Great! As if I didn’t have enough trouble today, I’ve got to deal with you guys! Go away. I don’t need any help!”

5. How would you proceed?

6. Back to Topics Functions of the Prehospital Care Report

7. Continuity of Medical Care Back to Objectives

8. Provides a baseline for other providers Gives an understanding of events and reasons for the call

9. Administrative Uses

10. Becomes part of patient record Used for billing Statistics

11. Legal Document

12. Is legal document May appear as a witness Can be months or years later May be a defense

13. Educational and Resource Uses

14. Can look at positive or negative effects May identify training needs

15. Evaluation and Continuous Quality Improvement

16. Documentation part of quality improvement Medical oversight

17. Back to Topics Collection of Data in Prehospital Care Reports

18. PCR Formats Back to Objectives

19. Written Computerized

20. PCR Data The Minimum Data Set Back to Objectives

21. Chief complaint Level of responsiveness Blood pressure Skin color, temperature, and condition Pulse rate Respiratory rate and effort Patient demographics Times of the call

22. PCR Data Administrative Information Back to Objectives

23. EMS unit and run or call number Names of crew and levels of certification Address to which unit is dispatched

24. PCR Data Patient Demographics and Other Patient Data

25. Legal name, age, sex, race, and birth date Home address Location where you found the patient Insurance/billing Care rendered prior to EMT arrival

26. PCR Data Vital Signs

27. At least two sets should be taken prior to arrival.

28. PCR Data Patient Narrative Back to Objectives

29. Chief complaint SAMPLE Objective data Subjective data Pertinent negatives

30. PCR Data Treatment

31. Time Effect on patient status

32. Back to Topics Legal Concerns

33. Confidentiality Back to Objectives

34. Information on PCR is confidential Be familiar with HIPAA

35. Distribution

36. Follow state rules and local protocol for PCR distribution Leave a copy of PCR at receiving facility (© Ray Kemp/911 Imaging)

37. Refusal of Treatment

38. Document competency Document your efforts completely Have patient sign refusal Offer patient alternate methods of getting care Remind patient that EMS can always return

39. Falsification

40. Do not try to cover up mistakes Do not compromise patient care

41. Falsification Correcting Errors

42. Draw single line, initial it, write the correct information beside it Do not erase Do not write over Back to Objectives

43. Back to Topics Special Situations

44. Transfer of Care Report

45. Obtain a signature from the medical professional who is assuming care Leave a copy of report with facility

46. Multiple-Casualty Incidents

47. Follow local MCI plan for record keeping Use triage tags (© Stephanie Ruet/Corbis Sygma)

48. Special Reports

49. Suspected abuse Exposures Injuries to EMS members Information for other agencies (© David Handschuh)

50. Back to Topics Alternative Documentation Methods

51. SOAP Back to Objectives

52. S – Subjective O – Objective A – Assessment P – Plan

53. CHART

54. C – Chief complaint H – History A – Assessment R – Rx T – Transport

55. CHEATED

56. C – Chief complaint H – History E – Exam A – Assessment T – Treatment E – Evaluation D – Disposition

57. Back to Topics Medical Abbreviations

58. Only use universally accepted medical abbreviations. Examples: BP – Blood pressure bpm – beats per minute CVA – Cerebrovascular accident CHF – Congestive heart failure Back to Objectives

59. Follow-Up CASE STUDY

60. Assessment CASE STUDY You notice he has a bruise above left eye You are able to calm patient He refuses all assessment and treatment

61. Documentation CASE STUDY You note all pertinent findings Document refusal Have Mr. Makynen read and sign refusal Suggest Mr. Makynen see a doctor or call 911 if things change Now clear and in service

62. 36-year-old female complaining of severe abdominal pain The patient is alert and oriented Vital signs: BP: 88/64 mmHg HR: 128 bpm with weak radial pulses RR: 24 with adequate chest rise Skin is pale, cool, and clammy SpO 2 is 96 percent on room air Critical Thinking Scenario

63. SAMPLE history: S – Feels light-headed and dizzy every time she stands up; she’s also nauseated A – No known allergies M – Over-the-counter Claritin for allergies P – No pertinent medical history; tonsils removed when she was ten years old L – Nothing to eat or drink for seven hours E – Has “not felt real good” for a few days Critical Thinking Scenario

64. Pain assessment: O – Pain began suddenly and has progressively worsened; was sitting on the couch watching television when it began P – Nothing makes it better or worse Q – Dull, aching, and intermittent R – Nonradiating S – Eight out of ten T – Four hours Critical Thinking Scenario

65. Physical exam: Pupils are equal and sluggish to respond Breath sounds are equal and clear bilaterally; no JVD Abdomen is rigid and tender; no evidence of trauma to the abdomen Good motor and sensory function in all four extremities; peripheral pulses are very weak Critical Thinking Scenario

66. Repeat vital signs: BP: 82/62 mmHg HR: 134 bpm, radial pulses barely palpable RR: 26 with adequate chest rise Skin is more pale, cool, and clammy Pulse oximeter reading “error” Critical Thinking Scenario

67. En route to the hospital, the patient begins to close her eyes You must verbally instruct her to open her eyes For your PCR documentation: Jennifer Sampson 1321 Oakridge Drive Smithville, Ohio Critical Thinking Scenario

68. 1.What can this information be used for? 2.How will the medical personnel in the medical facility use the information? 3.What will your EMS use the information for? 4.What would you document in the patient information section of the minimum data set? Critical Thinking Questions

69. 5.What would you document in the administrative section of the PCR? 6.What information would you write in the patient narrative section? 7.Should any of the information not be reported in the PCR? 8.If you were to make a mistake while writing the PCR, how would you correct it? Critical Thinking Questions

70. 9.If the PCR contains a box for a third set of vital signs, what would you document in this patient? 10.How would you collect additional information needed for your PCR? Critical Thinking Questions