1. Documentation
CHAPTER 15 1

2. The prehospital care report is an important medical and legal document.1

3. If you didn’t write it down...
…it didn’t happen! 1

4. Trending:
Comparing present information about a patient’s status with previously recorded information to detect changes or trends. 1

5. Accurate and complete documentation can contribute to quality assurance.10

6. Minimum Data Set 1

7. Minimum data set:
The essential elements of patient and administrative data required for accurate and complete prehospital data collection. 1

8. Patient Components Age and gender Chief complaint
Cause of injury/nature of illness
Past medical history
Signs and symptoms present
Injury description
Level of responsiveness (AVPU)
Pulse rate and blood pressure 1

9. Patient Components continued
Respiratory rate, depth and effort
Lung sounds
Skin perfusion (Capillary refill for patients <6 yrs)
Skin color, temperature and condition
Procedures performed on patient
Medications administered
Response to treatment
Document what the patient has done for themself and the effect 1

10. Administrative Components
Incident location
Date incident reported
Time incident reported
Date EMS unit notified
Time EMS unit notified
Time EMS unit responded
Time of arrival at scene
Time of arrival at patient’s side 1

11. Administrative Components continued
Time EMS unit left scene
Time of arrival at destination
Time of transfer of patient care
Time when EMS unit back in service
Use of lights & siren (to & from scene)
Crew members responding 1

12. All recorded data must be ACCURATE!1

13. The Prehospital Care Report
Functions of the Prehospital Care Report 1

14. Functions of the Prehospital Report
Helps ensure continuity of care
Legal document
Educational purposes
Administrative purposes
Research
Evaluation and quality improvement 1

15. The prehospital care report is a legal document...
...and is considered confidential. 1

16. Documented Information
Subjective information is not verifiable, but comes from another’s point of view.
Objective information is measurable or verifiable. 1

17. Traditional Format 1

18. Medical Reporting Format
Patient’s age and gender
Chief complaint
History of present illness or mechanism of injury
Pertinent past medical history
Mental status 1

19. Medical Reporting Format continued
Assessment or physical findings
Vital signs
Emergency care provided
Patient’s response to emergency care
Disposition of the patient 1

20. General Principles of the Narrative
Describe facts (avoid conclusions)
Record important observations of the scene
Only use standard abbreviations
Spell words correctly (especially medical terms)
Write legibly and neatly
Use printed text (rather than cursive) 1

21. Other Formats 1

22. Types of Written Formats
SOAP method
Head-to-toe method
Chronological method 1

23. Subjective
Objective
Assessment
Plan 1

24. Head-to-toe method: Findings documented as you move from head to toe.1

25. Chronological method:
Documentation based on the the chronological progress of the call. 1

26. EMS systems are starting to utilize computerized record systems similar to an electronic clipboard.1

27. Distribution 1

28. Typical Report Distribution
Original retained by agency
Copy to receiving facility
Copy to state or local government agency
Copy to medical director 1

29. Documentation Errors versus Patient Care Errors1

30. Errors in patient care must always be documented...1

31. …falsification of information in a prehospital care report is illegal!1

32. Correction of Documentation Errors1

33. A properly corrected error.
Patient describes pain as “crushing.” Severity is rated as a 6 on a scale of Pt. stated the pain began 1 hr. prior to EMS notification arrival. Pt. has a HX of hypertension and angina. Current meds NTG. JS
One line through error to keep it legible, then initial. 1

34. Errors discovered after a report is completed should be corrected with an ADDENDUM.1

35. Documentation of Patient Refusal1

36. Patient Refusal of Services
Refusal section of a prehospital care report.
Patient Refusal of Services
This is to certify that I, _________________ am refusing:
__ Treatment
__ Transport
__ Other: __________________________________________
I acknowledge that I have been informed of the risk(s) involved, and hereby release the EMS personnel, their agency, the medical director, and medical control facility from all responsibility for any ill effects which may result from this action.
Signature:_______________________ Date: ___________
Witness:_________________ Witness:_________________ 1

37. Even if the patient signs a refusal form...
...a prehospital patient care report MUST be completed. 1

38. Patient Refusal Documentation
A completed and signed refusal form
That the patient was informed of the possible adverse effects of refusal
Have a witness sign the form, a police officer, bystander or family member
If patient refuses to sign, have a witness sign attesting refusal 1

39. Multiple-Casualty Incidents
Special Situations
Multiple-Casualty Incidents 1

40. A triage tag may be used in an MCI.1

41. Special Situation Reports1

42. Special Situation Reports
Infectious disease exposure
Injury to EMS personnel or bystanders
Equipment damage or malfunction
Vehicle crashes involving the EMS unit
Patient refusals
Crime scenes
Hazardous materials incidents 1

43. SUMMARY Minimum Data Set The Prehospital Care Report
Documentation of Patient Refusal
Special Situations
SUMMARY 1