1. Chapter 20 Record

2. © 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 2 Overview  The Record  Principles of Documentation  Special Incident Reports  The EMT as a Good Citizen  Multiple-Casualty Incident  Patient Refusal Documentation

3. © 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 3 The Record  Problem-Oriented Medical Record Keeping (POMR) –Universal standard of documentation –Uses a problem or diagnosis as an index –Patient’s chief complaint is basis for EMT care

4. © 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 4

5. 5 The Record  Functions of the record –Prehospital PCR –Can speak for the patient –Can describe scene where patient was found

6. © 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 6 The Record  Functions of the record: Quality improvement –Administrative purposes tied to patient care Continuous quality improvement process Peer review process Call review process

7. © 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 7 The Record  Functions of the record: Research –Used to improve EMT practice Identifies what works and what does not work Helps identify ineffective treatments Helps underpin particular practice Suggests ways to improve care

8. © 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 8 The Record  Functions of the record: Administrative purposes –Not directly tied to patient’s care Billing information Information for other reports

9. © 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 9 The Record  Functions of the record: Legal document –Used in court of law –EMT must depend on PCR when testifying

10. © 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 10

11. © 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 11 The Record  Minimum data sets –Administrative data set –Medical data set –State and federal governments

12. © 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 12 The Record  Format for documentation: –Open format –Closed format –Hybrid format

13. © 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 13 The Record  Format for documentation: SOAP charting S = Subjective O = Objective A = Assessment P = Plan

14. © 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 14 The Record  Format for documentation: Extended charting methods –SOAPIE –CHART

15. © 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 15 The Record  Format for documentation: CHEATED charting C = Chief complaint H = History E = Examination A = Assessment T = Treatment E = Evaluation D = Disposition

16. © 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 16 Stop and Review  List four functions of the PCR.  List the elements of the acronym CHEATED.

17. © 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 17 Principles of Documentation  Be objective  Document only patient statements that clarify condition  Document all care  Be timely  Complete PCRs at point of transfer

18. © 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 18 Principles of Documentation  Documentation standards –The record must be readable –Use accurate abbreviations if used at all

19. © 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 19 Principles of Documentation  Documentation standards: Errors and corrections –Cross-outs –Do not use white correction fluid or black out –Initial last point –Add initials, date, and time to end of PCR –Documentation can be reopened when needed

20. © 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 20

21. © 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 21 Principles of Documentation  Documentation standards: Legibility –Write clearly –May use block printing –Use black ink

22. © 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 22 Special Incident Reports  Special incident report—for documentation of specific incidents –Injury to EMT –Infectious disease exposure –Equipment failure

23. © 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 23 Special Incident Report  Injury to EMT –Report injury immediately –Report serves as a basis for claim

24. © 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 24 Special Incident Report  Infectious disease exposure –Report EMT exposure –Give report to infection control officer –OSHA regulation –Follow local protocols

25. © 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 25 Special Incident Report  Equipment failure –File report when equipment fails on a call –Return report to a supervisor –Reports may be legal evidence

26. © 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 26 The EMT as Good Citizen  Patient care is always the EMT’s first responsibility  Other responsibilities  Report suspected abuse  Written testimony (affidavit)  Testifying in court  Agency procedure

27. © 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 27 Multiple-Casualty Incident  Half a dozen to a hundred or more patients  Triage tags

28. © 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 28 Patient Refusal Documentation  When patient refuses care –Document his decision-making –Patient refusal form –Consult EMS supervisor –Contact ED physician –Witness –Standardized refusal of medical assistance

29. © 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 29 Stop and Review  Describe how to correct an error in the record.  List several reasons to write a special incident report.