1. Copyright ©2012 by Pearson Education, Inc. All rights reserved. Emergency Care, Twelfth Edition Daniel J. Limmer O’Keefe Grant Murray Bergeron Dickinson Emergency Medical Responder: First on Scene, Ninth Edition Le Baudour Bergeron Wesley OA 2.4 Complete the follow phrases: “If you didn’t write it down,.” Documentation allows for a between healthcare providers.

2. Copyright ©2012 by Pearson Education, Inc. All rights reserved. Emergency Care, Twelfth Edition Daniel J. Limmer O’Keefe Grant Murray Bergeron Dickinson Emergency Medical Responder: First on Scene, Ninth Edition Le Baudour Bergeron Wesley CHAPTER Principles of Effective Documentation 7

3. Copyright ©2012 by Pearson Education, Inc. All rights reserved. Emergency Care, Twelfth Edition Daniel J. Limmer O’Keefe Grant Murray Bergeron Dickinson Emergency Medical Responder: First on Scene, Ninth Edition Le Baudour Bergeron Wesley Topics Patient Care Reports Methods of Documentation

4. Copyright ©2012 by Pearson Education, Inc. All rights reserved. Emergency Care, Twelfth Edition Daniel J. Limmer O’Keefe Grant Murray Bergeron Dickinson Emergency Medical Responder: First on Scene, Ninth Edition Le Baudour Bergeron Wesley PATIENT CARE REPORTS

5. Copyright ©2012 by Pearson Education, Inc. All rights reserved. Emergency Care, Twelfth Edition Daniel J. Limmer O’Keefe Grant Murray Bergeron Dickinson Emergency Medical Responder: First on Scene, Ninth Edition Le Baudour Bergeron Wesley Patient Care Reports Documentation you provide is a permanent record of patient care you performed. Reports called run reports, patient care reports, prehospital care. (continued)

6. Copyright ©2012 by Pearson Education, Inc. All rights reserved. Emergency Care, Twelfth Edition Daniel J. Limmer O’Keefe Grant Murray Bergeron Dickinson Emergency Medical Responder: First on Scene, Ninth Edition Le Baudour Bergeron Wesley Patient Care Reports Some done by hand; some computerized (electronic).

7. Copyright ©2012 by Pearson Education, Inc. All rights reserved. Emergency Care, Twelfth Edition Daniel J. Limmer O’Keefe Grant Murray Bergeron Dickinson Emergency Medical Responder: First on Scene, Ninth Edition Le Baudour Bergeron Wesley Example of a patient care report form.

8. Copyright ©2012 by Pearson Education, Inc. All rights reserved. Emergency Care, Twelfth Edition Daniel J. Limmer O’Keefe Grant Murray Bergeron Dickinson Emergency Medical Responder: First on Scene, Ninth Edition Le Baudour Bergeron Wesley Example of a patient care report form.

9. Copyright ©2012 by Pearson Education, Inc. All rights reserved. Emergency Care, Twelfth Edition Daniel J. Limmer O’Keefe Grant Murray Bergeron Dickinson Emergency Medical Responder: First on Scene, Ninth Edition Le Baudour Bergeron Wesley Electronic documentation of an emergency call is becoming more common.

10. Copyright ©2012 by Pearson Education, Inc. All rights reserved. Emergency Care, Twelfth Edition Daniel J. Limmer O’Keefe Grant Murray Bergeron Dickinson Emergency Medical Responder: First on Scene, Ninth Edition Le Baudour Bergeron Wesley Patient Care Reports Reasons for accurate and complete documentation: – Continuity of care – Education – Administration – Quality assurance – Legal

11. Copyright ©2012 by Pearson Education, Inc. All rights reserved. Emergency Care, Twelfth Edition Daniel J. Limmer O’Keefe Grant Murray Bergeron Dickinson Emergency Medical Responder: First on Scene, Ninth Edition Le Baudour Bergeron Wesley Patient Care Reports Elements of the PCR – Run data: information about call. – Patient data: patient information. Sections of the Report – Fill-in – Check boxes – Narrative

12. Copyright ©2012 by Pearson Education, Inc. All rights reserved. Emergency Care, Twelfth Edition Daniel J. Limmer O’Keefe Grant Murray Bergeron Dickinson Emergency Medical Responder: First on Scene, Ninth Edition Le Baudour Bergeron Wesley Patient Care Reports Information in narrative should be objective rather than subjective. – Objective: straightforward facts. – Subjective: up for interpretation; may include descriptions.

13. Copyright ©2012 by Pearson Education, Inc. All rights reserved. Emergency Care, Twelfth Edition Daniel J. Limmer O’Keefe Grant Murray Bergeron Dickinson Emergency Medical Responder: First on Scene, Ninth Edition Le Baudour Bergeron Wesley 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) (continued)

14. Copyright ©2012 by Pearson Education, Inc. All rights reserved. Emergency Care, Twelfth Edition Daniel J. Limmer O’Keefe Grant Murray Bergeron Dickinson Emergency Medical Responder: First on Scene, Ninth Edition Le Baudour Bergeron Wesley 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).

15. Copyright ©2012 by Pearson Education, Inc. All rights reserved. Emergency Care, Twelfth Edition Daniel J. Limmer O’Keefe Grant Murray Bergeron Dickinson Emergency Medical Responder: First on Scene, Ninth Edition Le Baudour Bergeron Wesley 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.

16. Copyright ©2012 by Pearson Education, Inc. All rights reserved. Emergency Care, Twelfth Edition Daniel J. Limmer O’Keefe Grant Murray Bergeron Dickinson Emergency Medical Responder: First on Scene, Ninth Edition Le Baudour Bergeron Wesley An example of how to properly document an error in documentation.

17. Copyright ©2012 by Pearson Education, Inc. All rights reserved. Emergency Care, Twelfth Edition Daniel J. Limmer O’Keefe Grant Murray Bergeron Dickinson Emergency Medical Responder: First on Scene, Ninth Edition Le Baudour Bergeron Wesley 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. Copyright ©2012 by Pearson Education, Inc. All rights reserved. Emergency Care, Twelfth Edition Daniel J. Limmer O’Keefe Grant Murray Bergeron Dickinson Emergency Medical Responder: First on Scene, Ninth Edition Le Baudour Bergeron Wesley METHODS OF DOCUMENTATION

19. Copyright ©2012 by Pearson Education, Inc. All rights reserved. Emergency Care, Twelfth Edition Daniel J. Limmer O’Keefe Grant Murray Bergeron Dickinson Emergency Medical Responder: First on Scene, Ninth Edition Le Baudour Bergeron Wesley 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.

20. Copyright ©2012 by Pearson Education, Inc. All rights reserved. Emergency Care, Twelfth Edition Daniel J. Limmer O’Keefe Grant Murray Bergeron Dickinson Emergency Medical Responder: First on Scene, Ninth Edition Le Baudour Bergeron Wesley 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.

21. Copyright ©2012 by Pearson Education, Inc. All rights reserved. Emergency Care, Twelfth Edition Daniel J. Limmer O’Keefe Grant Murray Bergeron Dickinson Emergency Medical Responder: First on Scene, Ninth Edition Le Baudour Bergeron Wesley 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.

22. Copyright ©2012 by Pearson Education, Inc. All rights reserved. Emergency Care, Twelfth Edition Daniel J. Limmer O’Keefe Grant Murray Bergeron Dickinson Emergency Medical Responder: First on Scene, Ninth Edition Le Baudour Bergeron Wesley Two types of electronic tablets used for documenting patient care.

23. Copyright ©2012 by Pearson Education, Inc. All rights reserved. Emergency Care, Twelfth Edition Daniel J. Limmer O’Keefe Grant Murray Bergeron Dickinson Emergency Medical Responder: First on Scene, Ninth Edition Le Baudour Bergeron Wesley Two types of electronic tablets used for documenting patient care.

24. Copyright ©2012 by Pearson Education, Inc. All rights reserved. Emergency Care, Twelfth Edition Daniel J. Limmer O’Keefe Grant Murray Bergeron Dickinson Emergency Medical Responder: First on Scene, Ninth Edition Le Baudour Bergeron Wesley 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.

25. Copyright ©2012 by Pearson Education, Inc. All rights reserved. Emergency Care, Twelfth Edition Daniel J. Limmer O’Keefe Grant Murray Bergeron Dickinson Emergency Medical Responder: First on Scene, Ninth Edition Le Baudour Bergeron Wesley Think About It How might electronic PCR be useful during an emergency with multiple patients? What legal circumstances might require review of a PCR?

26. Copyright ©2012 by Pearson Education, Inc. All rights reserved. Emergency Care, Twelfth Edition Daniel J. Limmer O’Keefe Grant Murray Bergeron Dickinson Emergency Medical Responder: First on Scene, Ninth Edition Le Baudour Bergeron Wesley SUMMARY

27. Copyright ©2012 by Pearson Education, Inc. All rights reserved. Emergency Care, Twelfth Edition Daniel J. Limmer O’Keefe Grant Murray Bergeron Dickinson Emergency Medical Responder: First on Scene, Ninth Edition Le Baudour Bergeron Wesley 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.

28. Copyright ©2012 by Pearson Education, Inc. All rights reserved. Emergency Care, Twelfth Edition Daniel J. Limmer O’Keefe Grant Murray Bergeron Dickinson Emergency Medical Responder: First on Scene, Ninth Edition Le Baudour Bergeron Wesley Summary PCRs Main Categories – Run data – Patient data Completed using combination of fill-ins, check boxes, and narrative areas.

29. Copyright ©2012 by Pearson Education, Inc. All rights reserved. Emergency Care, Twelfth Edition Daniel J. Limmer O’Keefe Grant Murray Bergeron Dickinson Emergency Medical Responder: First on Scene, Ninth Edition Le Baudour Bergeron Wesley 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 single line through mistake, enter correct information above or beside it, initial change.

30. Copyright ©2012 by Pearson Education, Inc. All rights reserved. Emergency Care, Twelfth Edition Daniel J. Limmer O’Keefe Grant Murray Bergeron Dickinson Emergency Medical Responder: First on Scene, Ninth Edition Le Baudour Bergeron Wesley 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.

31. Copyright ©2012 by Pearson Education, Inc. All rights reserved. Emergency Care, Twelfth Edition Daniel J. Limmer O’Keefe Grant Murray Bergeron Dickinson Emergency Medical Responder: First on Scene, Ninth Edition Le Baudour Bergeron Wesley REVIEW QUESTIONS

32. Copyright ©2012 by Pearson Education, Inc. All rights reserved. Emergency Care, Twelfth Edition Daniel J. Limmer O’Keefe Grant Murray Bergeron Dickinson Emergency Medical Responder: First on Scene, Ninth Edition Le Baudour Bergeron Wesley 1.What is the purpose of the PCR? 2.What elements are typically included in the PCR? 3.What are the tools used to complete documentation in the field? Review Questions

33. Copyright ©2012 by Pearson Education, Inc. All rights reserved. Emergency Care, Twelfth Edition Daniel J. Limmer O’Keefe Grant Murray Bergeron Dickinson Emergency Medical Responder: First on Scene, Ninth Edition Le Baudour Bergeron Wesley Please visit www.bradybooks.com and follow the Resource Central links to access content for this text. www.bradybooks.com