Documentation:Professionalism, INTEGRITY &

funding

Amy Gutman MDEMS Medical Director

prehospitalmd@gmail.com

Who Cares About Documentation?

• CYA!

• Data drives research; research drives outcomes

• CQI & research show you how good your department is, & highlight room for improvement

• You are professionals – your documentation should reflect this professionalism

• Not to be bitchy…but poor care (or the perception of poor care) reflects badly on me. You work under my license & at my discretion. Don’t piss me off.

But one Chart Doesn’t Change Patient Care, Does It?

What Did Data Do For SFD?

• Drove change to ETCO2-driven appropriate ventilation vs “hypo” or “hyper” ventilation

• Proved that EMTs & EMT-Ps apply high level technical & physiological information to improve cardiac arrest outcomes

• Improved ROSC from 22% to 38% & survival from 4% to 11% from ALLALL cardiac arrests in one year

• Changes in Policy:– Cardiac Arrest– Vehicle & Equipment Sanitation– No Hauls– Death-In-Field– Skills Tracking– Personnel Distribution

What Can Data Do For your fd?

• Justify personnel

• Defend increased number of response vehicles & transport units

• Show responsibility to the patient, as well as overall improved quality of care

• Move towards greatness – Identity strengths & weaknesses– Document and publish successes

Notebooks

• Every PCR generates 30-50 data points

• Every arrest provides an additional 16 data points

• Missing data weakens patient care, CQI, billing & research

Charting Methods

• It does not matter which methods you use, as long as the documentation is thorough, complete & professional

• Yes…spelling & punctuation count

DCHARTE & Soap

D Dispatch Time / Type

C CC

H History

A Assessment

R Rx at Scene

T Treatment Enroute

E Exemptions

S Subjective

O Observations

A Assessment

P Plan

SAMPLE – OPQRST

O Onset

P Provokes

Q Quality

R Radiation

S Severity (1-10 scale)

T Time

S SSX

A Allergies

M Meds

P PMH

L Last PO intake

E Events (i.e. MOI)

General ConceptsAKA “Don’t Overload the Truck”

Key areas of emt liability

• Bad Refusals– Failure to consider

“competency”

– Failure to document

• Negligence– Ordinary negligence vs.

Gross negligence

• Abandonment– Transfer of care

– Failure to document

• Patient Care Issues– Airway

– Spinal Immobilization

– Equipment Failure

– NV status

NEGLIGENCE elements

• Duty:– “Obligatory conduct owed by a person to another person.” – In tort law, duty is a legally sanctioned obligation, the breach of which results in

liability

• Breach: – “Failure to perform a duty owed to another; a failure to exercise that care which

a reasonable, prudent man would exercise under similar circumstances.”

• Damages: – “For actual harm resulting from the defendant’s wrongful act or omission”

• Proximate Cause:– “Results were caused by one’s conduct or omission.”

Barron’s Law Dictionary, Fifth Edition, 2003

Keep accurate times

•Dispatched to Scene

•Arrival On Scene •BLS & ALS

•Actions On Scene•i.e. Medications•i.e. Time to shock

•Time on Scene

•Departure to Hospital

•Arrival to Hospital

Abbreviations

• No home-grown abbreviations– DRT– DFU– BFN– LOL

SPELLING COUNTS

• If a jury looks at a chart full of basic errors, they will conclude that you are as sloppy at patient care as you are at documentation

Bystanders & transfers

• Include name, level of training, license number(s) of ANY medical personnel who have assisted at any point during assessment or patient care

• Include initials or badge number person writing the narrative

• When transferring care, document name/ position who accepts patient

This Is Not CSI

• Unless you’re a medical or forensic specialist don’t make assumptions– i.e. Entrance & exit wounds

• Explain what was found & how it appeared– “Infant was found face-down under her bed-sheets,

cold, mottled, cyanotic, with vomitus noted in oropharynx”

Charting

Chief Complaint

• Why did patient call 911?

• Pt’s words in quotes

• “Upon arrival found 54 yo F on couch. Pt reports “feeling like someone is sitting on my chest.”

» vs

• “Called to house for possible heart attack”

HPI

• Descriptive narrative telling a story from onset of symptoms, bystander involvement, prehospital

treatments to time of transfer

History Obtained from someone other than patient

• Indicate why– Language barrier– Disability

• Document who provided history– Translator– Family– Friend

PMH/ PSH

• Past Medical & Surgical– Medical / surgical– Similar presentations: “The last time my chest hurt this

much, I went to the cath lab”

• Allergies– Drug & reaction

• Medications– Write “BP med” if that is what pt states– Be as thorough as possible

Good emts aren’t Helped By bad Documentation

SAD BUT TRUE EXAMPLES

• “Arrived on scene, pt sick to her stomack, said she ate some food that may be bad. V/S normal. Placed pt in POC and transported to ER.”

• “On scene found patient drunk. He’s a regular who always gets drunk. He called for EMS to avoid going to jail. He stinks bad. We turned him over to PO.”

• “Caled 4 medcal raisins. Patience in floore. She wus sikk. She puuked on floore. Blud wus in the puok. She didn’t waunt us so we lift.”

Vitals are vital

• Complete Vitals:– BP– RR (effort / number)

– O2 sat / capnography

– HR– Temperature

• Repeat serially

• Note changes in pt status– If you do something…what

happened?

Dispatch

• Computer Aided Dispatch– Best Friend vs Worst Enemy– Only as good as the dispatchers

& dispatch tools

• Nature & Type of call

• Updates Enroute – CPR in progress

– Police on scene

MVC HPI

HPI should emphasize mechanism of injury

What Is missing from above HPI?

MVC HPI

• Types of vehicles involved

• Principal Direction of Force (PDOF)

• Speed of both vehicles

• Description of Damage/ Intrusion

• Number of Patients

• Position of Patients

• Death/ Serious Injury in Passenger

• Restraints

• Ambulatory at Scene

Trauma HPI

Assessment

• Your “impression” rather than a diagnosis

• Observations & subjective information

• “51 yo M with CP & ST elevations in II, III, AvF”

• “Provider Impression” – Essential for billing– Proof that pt had an ALS

assessment & treatment

Treatment

• All interventions

• Includes:– Bystander interventions

prior to your arrival– Your interventions– Any positive or negative

response to treatment• “Pt placed on 100%

NRB. Sat increased from 88 to 97%, RR decreased from 34 to 18/min”

Examples of “Treatments/ Interventions”

Other Treatments & Interventions

Transportation & triage

• Methods of transfer to unit & to hospital- Seated

- Supine

- C spine immobilization

• Any treatment initiated or continued while en-route– “VS reassessed q 15mins

– O2 at 10 LPM NRB due to decreased O2 sat from 99% RA to 90% RA”

Transportation & triage

• Document name & title of the person to which patient care was transferred

• Reason for Triage:– Closest facility– Trauma Triage– Patient request– If “Requesting” & “Transport” hospitals are different,

document why

Exceptions TO STANDARD OF CARE

• All treatments must be consistent with OEMS protocols

• Document everything that was done– If a standard treatment was not done,

why not? – Any “exception” from norm, i.e. “Patient

refused ASA due to known allergy”

• CYA - Justifies why you did or did not do something

• Keeps CQI & Medical Director off your back

Trauma Patients

• Trauma triage legislation requires providers to document if pt met criteria for transportation to a trauma center

• Try to justify using at least 2 criteria:– “Pt unconscious following

front-impact MVC. Transported to a Level 1 trauma center due to bilateral femur fractures.”

Refusals

• NEVER from pediatrics, or intoxicated/ confused adults

• Thoroughly document effort to provide informed consent including potential complications (use & write the word “death”)

• All refusals must be signed, including signatures by the patient/ guardian/ power of attorney, provider & witness– If police or family not available, your partner’s signature is adequate

• Refusals are the most common prehospital documents to show up in court – pay extra attention to spelling, grammar, punctuation, signatures, times & dates

DNRs / MOLST

• Patient can change mind at any time– “Patient requested EMS to disregard DNR”

• Include statement regarding DNR in PCR– Date document signed & who signed it

• If the paperwork is not physically present it does not exist

Cardiac arrest documentation

• Reportable to state & national registries

• Affects policy, national standards & patient outcomes

Utstein CA Data CollectionUtstein CA Data Collection

• Date / Time

• Incident Number

• Accepting Hospital

• Age / DOB

• Gender / Race

• Past Medical History

• Down Time

• Time to Patient Contact

• Time On Scene

• Witnessed Arrest

• Bystander CPR

• Initial & Serial Rhythms

• Initial & Serial Vitals

• Ventilation rate

• Initial & Serial ETCO2

• Any Interventions (meds, defibrillation)

• ROSC

• HPI Narrative

BASICSXXXXX

xx

xx

John Smith

111-11-1111

Good Narratives tell

“Stories”

•Should have “4 Point” intubation confirmation in narrative

•ETT visualized passing through cords

•ETCO2 confirmation

•BL breath sounds ausculated

•No epigastric sounds

Sloppy & Incomplete

This patient SURVIVED a cardiac arrest…wouldn’t it have been nice to know why?

Time to Patient ContactTime to Patient Contact

•NOT time “on scene”

•If BLS unit arrived first, document their interventions

•Time on scene also important to document; national standards are <10 mins

Witnessed Arrest & Bystander CPRWitnessed Arrest & Bystander CPR

• “Yes” or “No”

• Was AED was used on scene?

• Important for tracking community involvement & outcomes

• May help in receiving public health grants for education

Vitals are VITAL!

• If patient has no vitals or spontaneous respirations, document: – Rate at which you are ventilating patient– ETCO2

– Rate you are performing chest compressions

• New CPR Guidelines & ongoing research into the “best” resuscitation strategies

• ETCO2 is not just a number, it may be a predictor of outcome

Rhythm

• Initial

• Changes with any intervention

• Final rhythm at presentation to ED

FYI

• NV status before & after splinting & spinal immobilization

• Loose/ missing teeth prior to intubation

• Subjective “feelings” are assessments

• Protect patient confidentiality

• Falsification of EMS reports equals fraud

• Spelling, grammar & punctuation count – this is a legal document and reflects your professionalism

PUNCTUATION IS POWERFUL!

• An English professor wrote these words on a chalkboard and asked his students to punctuate it correctly:

• “A woman without her man is nothing”

• All of the males in the class wrote:• “A woman, without her man, is nothing”

• All of the females in the class wrote:• “A woman: without her, man is nothing”

Thanks For The Great Job You Do Everyday!

Any Questions? Amy.Gutman72@gmail.com