Chapter 016[1]

Copyright © 2007, 2005 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.

Chapter 16Chapter 16

DocumentationDocumentation


OverviewOverview Minimum Data SetMinimum Data Set The Prehospital Care ReportThe Prehospital Care Report

Functions of the Prehospital Care ReportFunctions of the Prehospital Care Report Traditional FormatTraditional Format Other FormatsOther Formats DistributionDistribution Documentation of Patient Care ErrorsDocumentation of Patient Care Errors Correction of Documentation ErrorsCorrection of Documentation Errors

Documentation of Patient RefusalDocumentation of Patient Refusal Special SituationsSpecial Situations

Multiple-Casualty IncidentsMultiple-Casualty Incidents Special Situation ReportsSpecial Situation Reports


Minimum Data SetMinimum Data Set Patient information gathered at time of EMT-Patient information gathered at time of EMT-

Basic’s initial contact with patient on arrival at Basic’s initial contact with patient on arrival at scene, following all interventions, and on arrival scene, following all interventions, and on arrival at facilityat facility Chief complaintChief complaint Level of consciousness (AVPU)—mental statusLevel of consciousness (AVPU)—mental status Systolic blood pressure for patients older than 3 years Systolic blood pressure for patients older than 3 years Skin perfusion (capillary refill) for patients younger Skin perfusion (capillary refill) for patients younger

than 6 years than 6 years Skin color and temperatureSkin color and temperature Pulse ratePulse rate Respiratory rate and effortRespiratory rate and effort


Minimum Data SetMinimum Data Set Administrative informationAdministrative information

Time incident reportedTime incident reported Time unit notifiedTime unit notified Time of arrival at patientTime of arrival at patient 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 Accurate and synchronous clocksAccurate and synchronous clocks


Prehospital Care ReportPrehospital Care Report

Functions of the prehospital care reportFunctions of the prehospital care report Continuity of careContinuity of care

• A form that is not read immediately in the emergency A form that is not read immediately in the emergency department may very well be referred to later for department may very well be referred to later for important informationimportant information



Functions of the prehospital care reportFunctions of the prehospital care report Legal documentLegal document

• A good report has documented what emergency medical A good report has documented what emergency medical care was provided and the status of the patient on arrival care was provided and the status of the patient on arrival at the scene and any changes on arrival at the receiving at the scene and any changes on arrival at the receiving facilityfacility

• The person who completed the form ordinarily must go to The person who completed the form ordinarily must go to court with the formcourt with the form

• Information should include objective and subjective Information should include objective and subjective information and be clearinformation and be clear



Functions of the prehospital care reportFunctions of the prehospital care report EducationalEducational

• Used to demonstrate proper documentation and how to Used to demonstrate proper documentation and how to handle unusual or uncommon caseshandle unusual or uncommon cases



Functions of the prehospital care reportFunctions of the prehospital care report AdministrativeAdministrative

• BillingBilling• Service statisticsService statistics• ResearchResearch• Evaluation and continuous quality improvementEvaluation and continuous quality improvement


Traditional FormatTraditional Format

Traditional written form with check boxes and Traditional written form with check boxes and a section for narrativea section for narrative


Traditional FormatTraditional Format

SectionsSections Run dataRun data

• Date, times, service, unit, names of crewDate, times, service, unit, names of crew


Traditional FormatTraditional Format SectionsSections

Patient dataPatient data• Patient namePatient name• AddressAddress• Date of birthDate of birth• Insurance informationInsurance information• SexSex• AgeAge• Nature of callNature of call• Mechanism of injuryMechanism of injury

• Location of patientLocation of patient• Treatment administered Treatment administered

prior to arrival prior to arrival • Signs and symptomsSigns and symptoms• Care administeredCare administered• Baseline vital signsBaseline vital signs• SAMPLE history SAMPLE history • Changes in conditionChanges in condition



Check boxesCheck boxes• Be sure to fill in the box completelyBe sure to fill in the box completely

• Avoid stray marksAvoid stray marks



Narrative section (if applicable)Narrative section (if applicable)• Describe, don’t concludeDescribe, don’t conclude

Include pertinent negativesInclude pertinent negatives Record important observations about the scene ( e.g., suicide Record important observations about the scene ( e.g., suicide

note, weapon)note, weapon) Avoid radio codesAvoid radio codes Use abbreviations only if they are standardUse abbreviations only if they are standard When information of a sensitive nature is documented, note When information of a sensitive nature is documented, note

the source of that information (e.g., communicable diseases)the source of that information (e.g., communicable diseases) Be sure to spell words correctly, especially medical wordsBe sure to spell words correctly, especially medical words For every reassessment, record time and findingsFor every reassessment, record time and findings


Patient Care ReportsPatient Care Reports

ConfidentialityConfidentiality The form itself and the information on the form are The form itself and the information on the form are

considered confidentialconsidered confidential


Patient Care ReportsPatient Care Reports

DistributionDistribution Local and state protocol and procedures will Local and state protocol and procedures will

determine where the different copies of the form determine where the different copies of the form should be distributedshould be distributed


Documentation of Patient CareDocumentation of Patient Care

When an error of omission or commission When an error of omission or commission occurs, the EMT-Basic should not try to cover occurs, the EMT-Basic should not try to cover it up it up

Instead, document what did or did not happen Instead, document what did or did not happen and what steps were taken (if any) to correct and what steps were taken (if any) to correct the situationthe situation



Falsification of information on the prehospital Falsification of information on the prehospital care report may lead to suspension or care report may lead to suspension or revocation of the EMT-Basic’s revocation of the EMT-Basic’s certification/license certification/license

Poor patient care may result because other Poor patient care may result because other health care providers have a false impression health care providers have a false impression of which assessment findings were of which assessment findings were discovered or what treatment was givendiscovered or what treatment was given



Specific areas of difficultySpecific areas of difficulty Vital signs—document only the vital signs that Vital signs—document only the vital signs that

were actually takenwere actually taken Treatment—if a treatment like oxygen was Treatment—if a treatment like oxygen was

overlooked, do not chart that the patient was given overlooked, do not chart that the patient was given oxygenoxygen


Correction of Documentation Correction of Documentation

Errors discovered while the report form is Errors discovered while the report form is being writtenbeing written Draw a single horizontal line through the error, Draw a single horizontal line through the error,

initial it, and write the correct information beside itinitial it, and write the correct information beside it Do not try to obliterate the error—this may be Do not try to obliterate the error—this may be

interpreted as an attempt to cover up a mistakeinterpreted as an attempt to cover up a mistake


Correction of DocumentationCorrection of Documentation

Errors discovered after the report form is Errors discovered after the report form is submittedsubmitted Preferably in a different color ink, draw a single line Preferably in a different color ink, draw a single line

through the error, initial and date it, and add a note with through the error, initial and date it, and add a note with the correct informationthe correct information

If information was omitted, add a note with the correct If information was omitted, add a note with the correct information, the date, and the EMT-Basic’s initialsinformation, the date, and the EMT-Basic’s initials


Correction of DocumentationCorrection of Documentation


Documentation of Patient RefusalDocumentation of Patient Refusal

Competent adult patients have the right to Competent adult patients have the right to refuse treatmentrefuse treatment


Documentation of RefusalDocumentation of Refusal Try to persuade the patient to go to a hospitalTry to persuade the patient to go to a hospital Ensure the patient is able to make a rational, Ensure the patient is able to make a rational,

informed decisioninformed decision Inform the patient why he or she should go Inform the patient why he or she should go

and what may happen to him if he does notand what may happen to him if he does not Consult medical direction Consult medical direction


Documentation of RefusalDocumentation of Refusal

Document any Document any assessment findings and assessment findings and emergency medical care emergency medical care given, then have the given, then have the patient sign a refusal formpatient sign a refusal form

Have a family member, Have a family member, police officer, or bystander police officer, or bystander sign the form as a witness sign the form as a witness


Documentation of RefusalDocumentation of Refusal

If the patient refuses to sign the refusal form, If the patient refuses to sign the refusal form, have a family member, police officer, or have a family member, police officer, or bystander sign the form verifying that the bystander sign the form verifying that the patient refused to signpatient refused to sign



Complete the prehospital care reportComplete the prehospital care report Complete patient assessmentComplete patient assessment Care EMT-Basic wished to provide for the patientCare EMT-Basic wished to provide for the patient Statement that the EMT-Basic explained to the patient Statement that the EMT-Basic explained to the patient

the possible consequences of failure to accept care, the possible consequences of failure to accept care, including potential deathincluding potential death

Offer alternative methods of gaining careOffer alternative methods of gaining care State willingness to returnState willingness to return


Special SituationsSpecial Situations

Multiple-casualty incidentsMultiple-casualty incidents

When there is not enough time to complete When there is not enough time to complete the form before the next call, the EMT-Basic the form before the next call, the EMT-Basic will need to fill out the report laterwill need to fill out the report later


Special SituationsSpecial Situations

The local MCI plan should have some means The local MCI plan should have some means of recording important medical information of recording important medical information temporarily (e.g., triage tag) that can be used temporarily (e.g., triage tag) that can be used later to complete the formlater to complete the form

The standard for completing the form in an The standard for completing the form in an MCI is not the same as for a typical call MCI is not the same as for a typical call

The local plan should have guidelinesThe local plan should have guidelines


Special Situation ReportsSpecial Situation Reports

Used to document events that should be Used to document events that should be reported to local authorities or to amplify and reported to local authorities or to amplify and supplement primary reportsupplement primary report

Should be submitted in timely mannerShould be submitted in timely manner Should be accurate and objectiveShould be accurate and objective The EMT-Basic should keep a copy for his own The EMT-Basic should keep a copy for his own

recordsrecords The report, and copies, if appropriate, should be The report, and copies, if appropriate, should be

submitted to the authority described by local submitted to the authority described by local protocolprotocol


Special Situation ReportsSpecial Situation Reports

Examples of incidents requiring special reportsExamples of incidents requiring special reports ExposureExposure InjuryInjury Equipment failureEquipment failure Ambulance crashAmbulance crash


Continuous Quality ImprovementContinuous Quality Improvement

Information gathered from the prehospital Information gathered from the prehospital care report can be used to analyze various care report can be used to analyze various aspects of the EMS systemaspects of the EMS system

This information can then be used to improve This information can then be used to improve different components of the system and different components of the system and prevent problems from occurringprevent problems from occurring


SummarySummary Minimum Data SetMinimum Data Set The Prehospital Care ReportThe Prehospital Care Report

Functions of the Prehospital Care ReportFunctions of the Prehospital Care Report Traditional FormatTraditional Format Other FormatsOther Formats DistributionDistribution Documentation of Patient Care ErrorsDocumentation of Patient Care Errors Correction of Documentation ErrorsCorrection of Documentation Errors

Documentation of Patient RefusalDocumentation of Patient Refusal Special SituationsSpecial Situations

Multiple-Casualty IncidentsMultiple-Casualty Incidents Special Situation ReportsSpecial Situation Reports

Chapter 016[1]

Health & Medicine

Transcript of Chapter 016[1]