DOCUMENTATION Pre-Hospital Patient Care Reports Jack Boyce, EMT-P Gates County Rescue & EMS...
-
Upload
gloria-flemming -
Category
Documents
-
view
218 -
download
2
Transcript of DOCUMENTATION Pre-Hospital Patient Care Reports Jack Boyce, EMT-P Gates County Rescue & EMS...
DOCUMENTATIONPre-Hospital Patient Care Reports
Jack Boyce, EMT-PGates County Rescue & EMSPasquotank-Camden County EMS
PURPOSES
Preserves basic patient informationRecords changes in patient conditionJustifies treatmentAllows continuity of careSatisfies regulatory requirements
PROVIDES
Protection for EMS personnelReflection of good patient care
Your Documentation Reflects Your PROFESSIONALISM
USES
MedicalAdministrativeResearchLegal
Medical Uses
Determine patient condition before arrival to hospital (mechanism of injury/nature of illness)
Chronological account of patient status Baseline for comparing assessment
findings and detecting trends of improvement or deterioration
This is part of the patients medical record, a copy of your
report MUST be left at the receiving facility
Administrative Uses
Gain information for quality improvement (detect a single providers weaknesses or EMS system weaknesses that could be improved upon)
System assessment (response times, call locations, use of lights and sirens)
Billing for reimbursement of services provided
Research Uses
To determine effectiveness of medical devices, drugs, and invasive procedures
Legal Uses
Permanent part of patients medical record May be your SOLE source of information in
court May be your BEST and ONLY defense in court
ALWAYS write your documentation as if you knew you would have to refer to it
someday in court
SHOULD BE
Accurate
Complete
Legible
Free of extraneous information
Should be written by the provider performing patient care
ALS personnel should remember that the highest certified technician
is in charge of not only their actions but the actions of other
crew members too
Accuracy
Document FACTS onlyDo NOT speculate about patient or
incidentAvoid reporting a diagnosis but instead
note primary/secondary impressions(EMS does not diagnose, DOCTORS diagnose)
Record observations, assessments, treatments/interventions, effects of treatments/interventions, re-assessments
Describe the patients condition on arrival of scene, during care, before and after interventions,
and upon arrival to hospital
Completeness
Include all requested informationFailure to document implies failure to
considerIf you look for something and it isn’t there,
include its absenceIf it ISN’T documented it DIDN’T happen
or WASN’T done
Document exactly WHAT you did, WHEN you did it, and the
EFFECTS of your interventions
Completeness
Document all findings of your assessment, even those that are normal (Pertinent Negatives)
Demonstrates thoroughness of examination
Helps rule out problemsEX: if a patient is having difficulty
breathing and has clear lung sounds with no edema you can rule out congestive heart failure
Completeness
If you contact medical control for orders or advice DOCUMENT IT
Legibility
Clear, legible documentation makes it difficult for other people to tamper with or misinterpret
When you have forgotten about an event and need to reference your documentation, if it is not legible events may remain unclear or misinterpreted
Remember that you are not the only person reading your report, other medical staff review your information to assist in quality improvement, research, legal and medical issues
A sloppy report = sloppy care
Legibility
If you use abbreviations make sure there meanings are clear and standardized
EX: “CP” – chest pain, cardiac perfusion, cerebral palsy
EX: “CO” – cardiac output, carbon monoxide
EX: “BLS” – basic life support, burns/lacerations/swelling
Legibility
When correcting mistakes, do it properlyDraw a single line through the error, write
the correct information beside it and initial the change
Extraneous Information
AVOID labeling patientsIf comments made by the patient need to
be included in your documentation preface them with “Per the patient…” or “Patient stated…”
AVOID humor, the public and the courts DO NOT regard EMS as a funny business
LIBEL – writing false or malicious words intended to damage a persons character
NARRATIVE SECTION
From a patient care and legal point of view this is the MOST IMPORTANT part of the
run report.
NARRATIVE SECTION
Your narrative should paint a picture of the scene, events leading up to the call, what
you found in your assessment, care provided, & how transferred to the hospital
Methods of Documentation
CHARTSOAPCHRONOLOGICAL
CHART
C = chief complaintH = historyA = assessmentR = treatmentT = transport
CHART
C = chief complaintChief complaint is what the patient is
complaining of exactly as the patient statesEX: C – pt states my chest hurts
CHART
H = historyUnder history you should include:
History of present illnessPast history
Current health status
CHART
A = assessmentUnder assessment you should include:
Vital signsGeneral impression
Physical examDiagnostic tests
CHART
R = treatmentUnder treatment you should include:
Standing orders (Protocols)Physician orders (Medical Direction)
(All treatments and interventions)
CHART
T = transportUnder transport you should include:
Effects of interventionsMode of transport
Ongoing assessments
SOAP
S = subjectiveO = objectiveA = assessmentP = plan
SOAP
S = subjectiveUnder subjective you should include:
Chief complaintHistory of present illness
Past historyCurrent health status
Family history
SOAP
O = objectiveUnder objective you should include:
Vital signsGeneral impression
Physical ExamDiagnostic tests
SOAP
A = assessmentUnder assessment you should include:
Field diagnosis
What you believe your patients problem is
SOAP
P = planUnder plan you should include:
Standing orders (Protocols)Physician orders (Medical Direction)
Effects of interventionsMode of transport
Ongoing assessment
CHRONOLOGICAL Start documenting from the time you were dispatched,
hitting high points and key events during call to include scene findings, patient assessment findings, interventions and outcomes. Narrative ends when you reach the point that the call is cleared.
Can be used in conjunction with actual event times or without by simply keeping events in order from beginning to end.
Ex: 1200 – arrived scene to find patient lying on ground responsive to painful stimuli, c-spine taken
1201 – airway assessed, patent and maintained by patient, patient breathing and has a pulse, rapid blood
sweep done finding no major life threatening bleeds, pt was backboarded, c- collar applied, CID in place, pt placed on 15 LPM O2 NRB
1215 – initial set of vitals taken, etc…
Patient Refusals
Patients retain the RIGHT to REFUSE treatment or transport IF they are
COMPETENT to make that decision
Reliable Patients
CALMCOOPERATIVESOBERALERTWITHOUT OTHER INJURIES
Unreliable Patients MAY Have:
Head/Brain injuries Altered Level of
Consciousness Intoxication Other distracting
injuries
AMA = AGAINST Medical Advice
Patient refuses care even though you feel they need it
Patient Refusals
Documentation checklist:Thorough patient assessment
Competency of patientYour recommendations for the need of care
and transportExplanation of possible consequences
INCLUDING DEATHPatients understanding of explanations
If there are any doubts in your mind about letting a patient
sign a refusal
CONTACT MEDICAL DIRECTION FOR ADVICE
Things to Include
Important observations – suicide notes, weapons, hostile family or bystanders
Patients refusal to have an area of their body assessed or difficulty to adequately assess an area
Devices used – backboards, scoop stretchers, splints, stair-chair, etc.
MVC’S
Type of collision Degree of damage Location of patient Use of restraint or safety devices
FALLS
How far did the patient fall?
What type of surface did the patient fall on?
What caused the patient to fall?
HEAD INJURIES
Level of consciousness Pupillary response Discharge from nose or
ears Battle signs Raccoon eyes Cervical pain,
tenderness, deformity Paralysis Altered motor function Altered sensory function
CHEST TRAUMA
Position of trachea Lung sounds JVD Paradoxical chest
movement or flail chest
Bruising Crepitus or pain with
palpation
Extremity Trauma
Color and Temp. Pulse, movement,
sensation (PMS) Any DCAPBTLS
Knife Wounds
Length and type of blade
Approx size of wound made
Gunshots (GSW)
Type of gun Caliber of gun, if
known Distance victim from
shooter Entry and exit
wounds
Patient Restraint
Be VERY specific of why you restrained the patient: behavior that you felt constituted a threat to patient or anyone else’s safety
Who restrained the patientWhat kind of restraints were usedNew injuries patient complains of during
and after restraintAreas of body restrained
Paperless
Many services throughout the country have started using electronic run reporting methods.
The state of North Carolina requires all EMS agencies to report data to the state PreMis system.
Though resistance is initially high, people quickly become dependent on the latest in patient care reporting technology.
Summary
Complete, accurate, legible documentation is an important key to– Providing continuity of patient care andrecording the event– Protection from litigation– Credibility as health care professionals– Financial reimbursement
ANY QUESTIONS OR THOUGHTS?
Quick Quiz
1. What are the 4 ways documentation is used in EMS?2. Since your PCR is part of the patient’s medical record, a copy
should be left where?3. Always write your documentation as if you knew you would have
to refer to it someday in _______?4. ______ is writing false or malicious words intended to damage a
persons character?5. Normal assessment findings are called _____ _____?6. From a patient care and legal point of view this is the most
important part of the run report?7. Patients retain the right to refuse treatment or transport if they are
______ to make that decision?8. Of the 3 narrative methods listed, which one do you prefer?
Narrative Evaluation
You respond to a 55 year old male complaining of chest pain
Make up a history for this patient, an assessment, and interventions/treatments
Create a narrative to document this call
Continuing Education Credit
Complete the 8 quiz questions and a practice narrative after reviewing this PowerPoint.
Include the quiz answers & narrative in a document and email to your instructor at [email protected]
You will receive 3 hours of con-ed credit after successful completion.