1. Chapter 4 Documentation Copyright ©2010 by Pearson Education, Inc. All rights reserved. Prehospital Emergency Care, Ninth Edition Joseph J. Mistovich Keith J. Karren

2. Objectives 1.Define key terms introduced in this chapter. 2.Describe each of the following purposes served by the prehospital care report (PCR) (slides 12-22):slides 12-22 a.Continuity of patient care b.Administrative uses c.Legal document d.Education and research e.Evaluation and continuous quality improvement (CQI) 3.Describe characteristics, including advantages and disadvantages, of both paper and computer-based (electronic) PCR formats (slides 23-24).slides 23-24

3. Objectives 4.Explain the purposes of the U.S. Department of Transportation (DOT) minimum data set for PCRs (slide 26).slide 26 5.List the elements of the DOT minimum data set for PCRs (slides 26-27).slides 26-27 6.Describe the purpose and contents of each of the following sections of a PCR (slides 28-37):slides 28-37 a.Administrative data b.Patient demographics and other patient data c.Vital signs d.Narrative e.Treatment

4. Objectives 7.Give examples of each of the following types of PCR narrative information (slides 34-35):slides 34-35 a.Chief complaint b.Pertinent history c.Subjective information d.Objective information e.Pertinent negatives 8.Use common abbreviations and medical terminology accurately in PCRs (slides 63-64).slides 63-64

5. Objectives 9.Explain each of the following legal concerns with respect to the PCR (slides 38-48):slides 38-48 a.Confidentiality b.Allowed distribution of the PCR or information included in it c.Documenting a patient’s refusal of treatment d.Falsification of the PCR e.Correction of errors

6. Objectives 10.Discuss how to handle each of the following situations with respect to the PCR (slides 48-55):slides 48-55 a.Transfer of patient care when returning to service prior to completing the PCR b.Multiple-casualty incidents (MCIs) c.Special reporting situations, such as infectious disease exposure and suspicion of abuse or neglect 11.Accurately and completely record pertinent patient and EMS call information using the SOAP, CHART, and CHEATED methods (slides 56-62).slides 56-62

7. Topics Functions of the Prehospital Care Report Collection of Data in Prehospital Care Reports Legal Concerns Special Situations Alternative Documentation Methods Medical Abbreviations

8. CASE STUDY Dispatch

9. EMS Unit 17 Respond to 57 Vallejo Road for a vehicle versus a parked car Time out 1321

10. Upon Arrival Female party who called 911 indicates the male who struck her vehicle was slumped over wheel States now he seems okay As you approach a mid-30s male he states, “Great! As if I didn’t have enough trouble today, I’ve got to deal with you guys! Go away. I don’t need any help!”

11. How would you proceed?

12. Back to Topics Functions of the Prehospital Care Report

13. Continuity of Medical Care Back to Objectives

14. Provides a baseline for other providers Gives an understanding of events and reasons for the call

15. Administrative Uses

16. Becomes part of patient record Used for billing Statistics

17. Legal Document

18. Is legal document May appear as a witness Can be months or years later May be a defense

19. Educational and Resource Uses

20. Can look at positive or negative effects May identify training needs

21. Evaluation and Continuous Quality Improvement

22. Documentation part of quality improvement Medical oversight

23. Back to Topics Collection of Data in Prehospital Care Reports

24. PCR Formats Back to Objectives

25. Written Computerized

26. PCR Data The Minimum Data Set Back to Objectives

27. Chief complaint Level of responsiveness Blood pressure Skin color, temperature, and condition Pulse rate Respiratory rate and effort Patient demographics Times of the call

28. PCR Data Administrative Information Back to Objectives

29. EMS unit and run or call number Names of crew and levels of certification Address to which unit is dispatched

30. PCR Data Patient Demographics and Other Patient Data

31. Legal name, age, sex, race, and birth date Home address Location where you found the patient Insurance/billing Care rendered prior to EMT arrival

32. PCR Data Vital Signs

33. At least two sets should be taken prior to arrival.

34. PCR Data Patient Narrative Back to Objectives

35. Chief complaint SAMPLE Objective data Subjective data Pertinent negatives

36. PCR Data Treatment

37. Time Effect on patient status

38. Back to Topics Legal Concerns

39. Confidentiality Back to Objectives

40. Information on PCR is confidential Be familiar with HIPAA

41. Distribution

42. Follow state rules and local protocol for PCR distribution Leave a copy of PCR at receiving facility (© Ray Kemp/911 Imaging)

43. Refusal of Treatment

44. Document competency Document your efforts completely Have patient sign refusal Offer patient alternate methods of getting care Remind patient that EMS can always return

45. Falsification

46. Do not try to cover up mistakes Do not compromise patient care

47. Falsification Correcting Errors

48. Draw single line, initial it, write the correct information beside it Do not erase Do not write over Back to Objectives

49. Back to Topics Special Situations

50. Transfer of Care Report

51. Obtain a signature from the medical professional who is assuming care Leave a copy of report with facility

52. Multiple-Casualty Incidents

53. Follow local MCI plan for record keeping Use triage tags (© Stephanie Ruet/Corbis Sygma)

54. Special Reports

55. Suspected abuse Exposures Injuries to EMS members Information for other agencies (© David Handschuh)

56. Back to Topics Alternative Documentation Methods

57. SOAP Back to Objectives

58. S – Subjective O – Objective A – Assessment P – Plan

59. CHART

60. C – Chief complaint H – History A – Assessment R – Rx T – Transport

61. CHEATED

62. C – Chief complaint H – History E – Exam A – Assessment T – Treatment E – Evaluation D – Disposition

63. Back to Topics Medical Abbreviations

64. Only use universally accepted medical abbreviations. Examples: BP – Blood pressure bpm – beats per minute CVA – Cerebrovascular accident CHF – Congestive heart failure Back to Objectives

65. Follow-Up CASE STUDY

66. Assessment CASE STUDY You notice he has a bruise above left eye You are able to calm patient He refuses all assessment and treatment

67. Documentation CASE STUDY You note all pertinent findings Document refusal Have Mr. Makynen read and sign refusal Suggest Mr. Makynen see a doctor or call 911 if things change Now clear and in service

68. 36-year-old female complaining of severe abdominal pain The patient is alert and oriented Vital signs: BP: 88/64 mmHg HR: 128 bpm with weak radial pulses RR: 24 with adequate chest rise Skin is pale, cool, and clammy SpO 2 is 96 percent on room air Critical Thinking Scenario

69. SAMPLE history: S – Feels light-headed and dizzy every time she stands up; she’s also nauseated A – No known allergies M – Over-the-counter Claritin for allergies P – No pertinent medical history; tonsils removed when she was ten years old L – Nothing to eat or drink for seven hours E – Has “not felt real good” for a few days Critical Thinking Scenario

70. Pain assessment: O – Pain began suddenly and has progressively worsened; was sitting on the couch watching television when it began P – Nothing makes it better or worse Q – Dull, aching, and intermittent R – Nonradiating S – Eight out of ten T – Four hours Critical Thinking Scenario

71. Physical exam: Pupils are equal and sluggish to respond Breath sounds are equal and clear bilaterally; no JVD Abdomen is rigid and tender; no evidence of trauma to the abdomen Good motor and sensory function in all four extremities; peripheral pulses are very weak Critical Thinking Scenario

72. Repeat vital signs: BP: 82/62 mmHg HR: 134 bpm, radial pulses barely palpable RR: 26 with adequate chest rise Skin is more pale, cool, and clammy Pulse oximeter reading “error” Critical Thinking Scenario

73. En route to the hospital, the patient begins to close her eyes You must verbally instruct her to open her eyes For your PCR documentation: Jennifer Sampson 1321 Oakridge Drive Smithville, Ohio Critical Thinking Scenario

74. 1.What can this information be used for? 2.How will the medical personnel in the medical facility use the information? 3.What will your EMS use the information for? 4.What would you document in the patient information section of the minimum data set? Critical Thinking Questions

75. 5.What would you document in the administrative section of the PCR? 6.What information would you write in the patient narrative section? 7.Should any of the information not be reported in the PCR? 8.If you were to make a mistake while writing the PCR, how would you correct it? Critical Thinking Questions

76. 9.If the PCR contains a box for a third set of vital signs, what would you document in this patient? 10.How would you collect additional information needed for your PCR? Critical Thinking Questions

77. Reinforce and Review Please visit www.bradybooks.com www.bradybooks.com and follow the myBradykit links to access content for the text.