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 jack.boyce@gatesrescue.org

You will receive 3 hours of con-ed credit after successful completion.