1. Documentation

2. Documentation Purposes Preserves basic patient information
Records changes in patient condition
Justifies treatment
Allows continuity of care
Satisfies regulatory requirements
Provides data for quality control

3. Documentation Protection for EMS personnel
Reflection of good patient care

4. Documentation
An accurate, complete, legible medical record implies accurate, complete, organized assessment and management

5. Documentation Characteristics of good medical record Accurate Complete
Legible
Free of extraneous information

6. Accurate Document facts, observations only
Do NOT speculate about patient or incident
Double-check numerical entries
Recheck spellings of:
Persons
Locations
Medical terms

7. If you make a mistake, document it.
Accurate
If you make a mistake, document it.
It is better to record your own mistakes that for someone else to uncover them.

8. Complete Include all requested information
If information requested does not apply, note “not applicable” or “N/A”
Include at least two sets of vital signs on every patient
Failure to document implies failure to consider
If you look for something and it isn’t there, document its absence

9. IF IT ISN’T DOCUMENTED, IT WASN’T DONE!
Complete
IF IT ISN’T DOCUMENTED, IT WASN’T DONE!

10. Legible
If you cannot read the report, you may be unable to determine what happened
Documents presented in court must “speak for themselves”
If a document cannot be deciphered, the jury has to right to ignore it altogether

11. Legible
If the report is sloppy, others will assume that the care was equally sloppy

12. Free of Extraneous Information
Avoid labeling patients (“drunk”, “psych patient”)
Describe the observations you made
Preface comments made by the patient with “per the patient” or “patient stated”

13. Free of Extraneous Information
Record hearsay only if applicable
Do NOT record hearsay as facts
Use quotation marks only if a statement is accurate word-for-word

14. Free of Extraneous Information
Avoid interjecting humor
The public does not regard EMS as a funny business

15. Documentation
A copy of the report must be left with the patient at the receiving hospital
State law requires this
Patient care has not legally been transferred until the hospital has your written report

16. Documentation The person who rode with the patient writes the report
All personnel who participated in care should review the report

17. Documentation If something needs to be corrected, correct it
The sooner an error is corrected, the more credible and reliable the change is
Mark through information so it is still readable
Then write in the new information and initial/date the change

18. If you have a long report, don’t hesitate to use additional pages
Documentation
If you have a long report, don’t hesitate to use additional pages

19. Documentation Avoid stating diagnostic impressions
Report facts and observations
If you must state a diagnostic impression
Do so within the scope of your training
Include the observations that led to the impression

20. Documentation
Avoid using “possible” or “?” when the observation would have been obvious to anyone

21. Documentation
Be sure treatments recorded match the mechanism of injury or the diagnostic impression
If something should have been done that was not, state why

22. Documentation
If spaces are provided for documenting times, fill them in carefully
Failing to document times implies lack of concern about the time factor
If you have a prolonged scene time, say why

23. Documentation
If you put a monitor on the patient, a hard copy of the EKG should accompany the report

24. Documentation
If a patient complains of pain in a area, state what you found when you examined the area
Failure to record your observations implies that you noted the complaint, but did not investigate it

25. Documentation On MVCs, report
Type of collision (head-on, roll-over, lateral impact, etc.)
Degree of damage to vehicles
Location of patients
Use of seatbelts

26. Documentation On falls report: Where the patient fell from
How far the patient fell
The surface the patient fell onto
Why the patient probably fell

27. Documentation On head injuries report: Level of consciousness
Pupillary responses

28. Documentation On head injuries report: Presence/absence of:
Discharge from nose and ears
Cervical pain, muscle spasm, tenderness, deformity
Paresthesias
Altered motor function
Altered sensory function

29. Documentation On chest injuries report: Position of trachea
Status of neck veins, breath sounds, heart sounds
Presence or absence of
Crepitus
Subcutaneous air
Paradoxical movement of chest wall

30. Documentation On extremity injuries report:
Distal skin color and temperature
Presence or absence of:
Distal pulses
Motor function
Sensory function

31. Good Documentation is NOT C.Y.A
Good Documentation is a Reflection of Good Patient Care

32. Refusals These can be the most problematic patients
Transport involuntarily- may face allegations of assault, battery or false imprisonment
Leave pt behind-may be accused of negligence or abandonment

33. Refusal policies Many are inadequate
Some rely on inappropriate criteria
Some are too abbreviated
Some give false sense of security
Laws may vary from one jurisdiction to the next
Essential elements- competence, documentation, and supervision

34. Competence
Well-informed, mentally competent adults have the right to refuse or accept care
This right of refusal is by no means absolute
In a medical emergency, EMS personnel may force a pt. rendered mentally incompetent by illness, injury, or intoxication to accept life-saving care
Challenge-which patient should be presumed incompetent

35. Historically- if pt is aware of person, place and time then they are allowed to refuse care…Don’t make this mistake.
Because an oriented pt may not possess the ability to process information effectively, focus on pt’s comprehension.
Patient should be able to understand the nature of the condition, risks and benefits of proposed treatment, risks and benefits of refusing care.

36. Before accepting a refusal, explain the nature of the emergency and the risks and benefits of treatment and refusal, then ask the patient to explain in their own words what they were told to determine if the understand all three elements.

37. Documentation This is vital
If a lawsuit arises years after the incident, the documentation will provide the facts as the memories of the involved parties will fade and/or change.
Report should include, at a minimum- physical exam with vital signs, factors affecting pt’s ability to reason (i.e. drugs or alcohol), the treatment offered.

38. Ask the patient to sign a release/refusal form
The supplements the patient care report
Helps show that the patient, not the EMS personnel, made the decision
Ask any witnesses as well to sign this form

39. Refusal/Release form
Must state more than the fact that the pt refused transport
Must indicate that the pt was advised of the suspected medical condition and that they understand the nature of the proposed treatment and potential consequences of refusal
Should be advised and drafted by an attorney and may want to consider including a release – from – liability provision

40. Supervision
Whenever possible medical control should be consulted to supervise a pt’s refusal.
In the case of a lawsuit, a physician’s testimony may support that the filed providers handled the situation correctly.

41. 12 item checklist 1. physical exam and vital signs
2. history of event and past medical history including medications
3. pt or decision-maker is capable of refusing medical care
4. risks of refusal of care and transport explained
5. benefits of medical care and transport explained
6.pt clearly offered medical care and/or transport

42. 7. refusal form prepared, explained, signed, and witnessed
8. pt confirmed to have understanding of the risks and benefits involved in their decision
9. pt advised to seek medical attention for complaint
10. pt advised to call 911 if condition continues or worsens
11. base consultation occurred according to local policy
12. supervisor notified if any of the above not accomplished

43. By implementing these standards when it comes to refusal, EMS systems may significantly reduce their liability.