1. Copyright © 2004, Mosby Inc. All rights reserved.

2. Documentation Chapter 15 Slide 1 Copyright © 2004, Mosby Inc. All rights reserved.

3. Case History You have been working as an EMT-Basic for 6 years. Your supervisor informs you that you are to testify in a lawsuit the day after tomorrow. The lawsuit pertains to an ambulance call you had 4 years ago. Not remembering the call very well, you look at the prehospital care report (PCR) to refresh your memory. You find that the PCR is incomplete and illegible. You have been working as an EMT-Basic for 6 years. Your supervisor informs you that you are to testify in a lawsuit the day after tomorrow. The lawsuit pertains to an ambulance call you had 4 years ago. Not remembering the call very well, you look at the prehospital care report (PCR) to refresh your memory. You find that the PCR is incomplete and illegible. Slide 2 Copyright © 2004, Mosby Inc. All rights reserved.

4. Documentation Minimum data setMinimum data set  National standard for essential documentation Critical for EMT to document action clearlyCritical for EMT to document action clearly Best legal defenseBest legal defense Important to patient careImportant to patient care Slide 3 Copyright © 2004, Mosby Inc. All rights reserved.

5. Functions of a Prehospital Care Report Continuity of careContinuity of care Legal documentLegal document Good reportGood report  Times  Assessment findings  Patient care  Changes on arrival at the receiving facility Slide 4 Copyright © 2004, Mosby Inc. All rights reserved.

6. Functions of a Prehospital Care Report EducationalEducational AdministrativeAdministrative  Billing  Service statistics ResearchResearch Evaluation and continuous quality improvementEvaluation and continuous quality improvement Slide 5 Copyright © 2004, Mosby Inc. All rights reserved.

7. Continuous Quality Improvement Used to analyze various aspects of the EMS systemUsed to analyze various aspects of the EMS system Used to improve different components of the systemUsed to improve different components of the system Prevents problems from occurringPrevents problems from occurring Slide 6 Copyright © 2004, Mosby Inc. All rights reserved.

8. Administrative Information Time incident reportedTime incident reported Time unit notifiedTime unit notified Time of arrival at patientTime of arrival at patient Slide 7 Copyright © 2004, Mosby Inc. All rights reserved.

9. Administrative Information Time unit left sceneTime unit left scene Time of arrival at destinationTime of arrival at destination Time of transfer of careTime of transfer of care Patient disposition informationPatient disposition information Slide 8 Copyright © 2004, Mosby Inc. All rights reserved.

10. Principles of Record Keeping Accuracy and honestyAccuracy and honesty ClarityClarity CompletenessCompleteness Chronology and trends (see below)Chronology and trends (see below) Slide 9 Copyright © 2004, Mosby Inc. All rights reserved.

11. Sections of a Prehospital Care Report Run dataRun data  Date, times, service, unit, names of crew Patient dataPatient data  Patient name, address, date of birth  Insurance information  Sex, age, nature of call, mechanism of injury  Location of patient Slide 10 Copyright © 2004, Mosby Inc. All rights reserved.

12. Sections of a Prehospital Care Report Patient dataPatient data  Treatment administered before arrival of EMT  Signs and symptoms  Care administered, baseline vital signs  SAMPLE history  Changes in condition Slide 11 Copyright © 2004, Mosby Inc. All rights reserved.

13. Narrative Section Describe, don't conclude.Describe, don't conclude. Include pertinent negative findings.Include pertinent negative findings. Record important observations about the scene (e.g., suicide note, weapon).Record important observations about the scene (e.g., suicide note, weapon). Avoid radio codes.Avoid radio codes. Spell words correctly.Spell words correctly. Use standard abbreviations.Use standard abbreviations. Slide 12 Copyright © 2004, Mosby Inc. All rights reserved.

14. Narrative Section Information of a sensitive nature (e.g., communicable diseases)Information of a sensitive nature (e.g., communicable diseases)  Note the source. State reporting requirementsState reporting requirements For every reassessment, record time and findingsFor every reassessment, record time and findings Other state or local requirementsOther state or local requirements Slide 13 Copyright © 2004, Mosby Inc. All rights reserved.

15. Types of Reports WrittenWritten  Check boxes  Section for narrative ComputerizedComputerized  Information entered onto electronic clipboard Slide 14 Copyright © 2004, Mosby Inc. All rights reserved.

16. Patient Data Chief complaintChief complaint Level of consciousnessLevel of consciousness  AVPU Systolic blood pressure for patients > 3 years oldSystolic blood pressure for patients > 3 years old Skin perfusionSkin perfusion Capillary refill for patients < 6 years oldCapillary refill for patients < 6 years old Slide 15 Copyright © 2004, Mosby Inc. All rights reserved.

17. Patient Data Skin color and temperatureSkin color and temperature Pulse ratePulse rate Respiratory rate and effortRespiratory rate and effort Slide 16 Copyright © 2004, Mosby Inc. All rights reserved.

18. Patient Refusal Complete report.Complete report. Complete patient assessment.Complete patient assessment. Note care EMT wished to provideNote care EMT wished to provide Statement that EMT explainedStatement that EMT explained  Possible consequences  Including potential death Offer alternative methods of gaining care.Offer alternative methods of gaining care. State willingness to return.State willingness to return. Slide 17 Copyright © 2004, Mosby Inc. All rights reserved.

19. Documentation of Patient Refusal Competent adults have the right to refuse treatment.Competent adults have the right to refuse treatment. Ensure patient is able to make an informed decision.Ensure patient is able to make an informed decision.  No alcohol or other drugs  No impaired judgment Inform the patientInform the patient  Why he or she should go to the hospital  What may happen if he or she does not go Consult medical direction, as directed by local protocol.Consult medical direction, as directed by local protocol. Slide 18 Copyright © 2004, Mosby Inc. All rights reserved.

20. Special Situation Reports Used to document events reported to local authoritiesUsed to document events reported to local authorities Amplify and supplement primary reportAmplify and supplement primary report Should be accurate and objectiveShould be accurate and objective Should be submitted in timely mannerShould be submitted in timely manner EMT should keep a copyEMT should keep a copy Follow local protocolFollow local protocol Slide 19 Copyright © 2004, Mosby Inc. All rights reserved.

21. Special Situation Reports Documentation of deathDocumentation of death Emotionally disturbed, underage, or unconscious patientsEmotionally disturbed, underage, or unconscious patients Dying statements Dying statements Homicide and suicide Homicide and suicide Slide 20 Copyright © 2004, Mosby Inc. All rights reserved.

22. Falsification Issues Never cover up an error or omission.Never cover up an error or omission.  Document what did or did not happen.  Steps that were taken (if any) to correct the situation FalsificationFalsification  May lead to suspension or revocation of certification/license  Poor patient care Slide 21 Copyright © 2004, Mosby Inc. All rights reserved.

23. Areas of Difficulty Vital signsVital signs  Document only the vital signs that were actually taken. TreatmentTreatment  If a treatment (such as oxygen) was overlooked, do not chart that the patient was given oxygen. Slide 22 Copyright © 2004, Mosby Inc. All rights reserved.

24. Correction of Errors General rulesGeneral rules  Cross out error.  Enter corrected data.  Initial next to correction.  Errors that are recorded at a later time »Use different colored ink. »Include the date. Slide 23 Copyright © 2004, Mosby Inc. All rights reserved.

25. Triage Tags Timesaving method Used in MCIs Focus on the essentials of care Establishes priority of patients Slide 24 Copyright © 2004, Mosby Inc. All rights reserved.

26. Documenting Death Death should be documented by recording physical finding such asDeath should be documented by recording physical finding such as  Decomposition  Extreme dependent lividity  Rigor mortis  Obvious lethal injuries (e.g., decapitation) “Patient found facedown in bed with rigor mortis and extreme dependent lividity on the anterior surface of the body.” Slide 25 Copyright © 2004, Mosby Inc. All rights reserved.

27. Confidentiality PCR is considered confidential.PCR is considered confidential. Be familiar with state laws.Be familiar with state laws. DistributionDistribution  Follow local and state protocol and procedures Slide 26 Copyright © 2004, Mosby Inc. All rights reserved.