1. 8
Principles of Effective Documentation

2. Objectives Define the following terms:
Continuity of care
Electronic documentation
Minimum data set
Patient Care Report (PCR)
Explain the purpose of the patient care report.
Describe the elements of a typical patient care report.
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3. Objectives
Describe the minimum data set required for the documentation of patient care.
Explain the procedure for correcting errors made during documentation.
List various tools used to document patient care in the field setting.
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4. Objectives
Demonstrate the ability to accurately document a simulated patient encounter.
Properly correct an error made during documentation.
Value the importance of complete and accurate documentation.

5. Topics
Patient Care Reports Methods of Documentation

6. PATIENT CARE REPORTS

7. Patient Care Reports
Documentation is a permanent record of provided care.
Reports may be handwritten or electronic and recognized by different titles.
Run reports
Patient care reports
Prehospital care reports
Discussion Question: Why should you create accurate and detailed documentation?

8. Figure 8.1 Example of a typical paper-style patient care report (PCR) form.

9. Figure 8.2 Electronic documentation of an emergency call is becoming more common.

10. Patient Care Reports Reasons for accurate and complete documentation
Continuity of care
Education
Administration
Quality assurance
Legal
Discussion Question: How can PCRs be made more accurate? What are some potential barriers?

11. Patient Care Reports Elements of the PCR Sections of the Report
Run data
Information about call
Patient data
Patient information
Sections of the Report
Fill-in
Check boxes
Narrative
Teaching Tip: Require documentation following all in-class simulated calls. Create a QI group to conduct peer review (change this group weekly so every student gains the experience).

12. Patient Care Reports
Information in narrative should be objective rather than subjective.
Objective
Straightforward facts
Subjective
Up for interpretation
May include descriptions
Class Activity: Provide a sample scenario patient simulation for an emergency call involving an unresponsive trauma victim with no witnesses and a high suspicion of assault Direct students to write a narrative based on what they encountered from beginning to end; being careful to document objectively rather than subjectively. Share narratives and discuss. (Consider having a teaching assistant or volunteer in moulage, placed in a room where there appears to have been a struggle. Ensure that students document only what they see, not what they assume).

13. Patient Care Reports Minimum Data Set
Time incident was reported to 911
Time of dispatch
Time of arrival at patient's location
Time patient was transported from incident location
Time patient arrived at destination (e.g., hospital, aid station)
Discussion Question: Why is data collection so important?
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14. Patient Care Reports Minimum Data Set
Time patient care was transferred to more advanced providers
Patient's chief complaint
Patient's vital signs
Patient's demographics
Age, gender, race, weight
Discussion Question: When would it be important to include more information than is required for a minimum data set?

15. Patient Care Reports Correcting Errors
Cross out incorrect item with single line, initial it, write correct number beside or above it.
Never completely cover incorrect information.
It may appear you are attempting to hide something.
Discussion Question: What types of errors on a PCR might be acceptable to correct? When might it not be acceptable to correct a PCR?

16. Figure 8.3 An example of how to properly document an error in documentation.

17. Think About It
The quality of your documentation is reflective of the care you provide.
How can data collection benefit EMS?
What elements would be essential to document for a refusal of care?

18. METHODS OF DOCUMENTATION

19. Methods of Documentation
Paper forms
PCR forms filled out by hand
Computer-scan forms
PCR forms completed by hand
Fill-in-the-bubble format can be scanned into computer for information management and statistics gathering.
Talking Point: Electronic PCR is widespread. The EMR needs to be familiar with the different electronic documentation hardware and software available.

20. Methods of Documentation
PDAs or handheld computers
Specialized software allows emergency care professionals to enter PCR information.
Information then downloaded to computer devices at hospital, base, or main office
Discussion Question: How might electronic PCRs be beneficial? Why might a paper PCR be preferred?

21. Methods of Documentation
Laptop computers
Software allows responders to complete PCR on computer and print from docking station or send wirelessly to hospital or central database.
Class Activity: If the technology is available, allow students to complete a sample PCR based on a provided scenario using electronic PCR software.

22. Figure 8.4 A typical electronic tablet used for documenting patient care.

23. Methods of Documentation
Data-enabled cellular devices
Advanced cellular data devices operate PCR applications to complete and send documentation quickly and easily from cellular phones.

24. Think About It
How might electronic PCR be useful during an emergency with multiple patients?
What legal circumstances might require review of a PCR?
Talking Point: Believe it or not, hospital staff read PCRs! Sometimes PCRs are read days after the emergency when the patient is an inpatient and a physician wants more details about what occurred prior to admission. Do not underestimate the value of documentation!

25. SUMMARY

26. Summary Patient care documentation is important.
Continuity of medical care to legal proceedings
Becomes permanent part of patient's medical record
Can be used by EMS organizations to improve overall quality of emergency services
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27. Summary PCR main categories
Run data
Patient data
Completed using combination of fill-ins, check boxes, and narrative areas
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28. Summary
Each PCR has a minimum data set as defined by U.S. Department of Transportation.
Documentation errors should be corrected without trying to obscure erroneous information.
Put a single line through mistake, enter correct information above or beside it, initial change.
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29. Summary Patient care documentation completed
Traditional paper-based forms
High-tech handheld computers
Data-enabled cellular devices
Ensure accuracy and avoid subjectivity when documenting what happened on each response.

30. REVIEW QUESTIONS

31. Review Questions What is the purpose of the PCR?
What elements are typically included in the PCR?
What are the tools used to complete documentation in the field?

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