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A patient suffers a diabetic emergency She is treated by the local EMS crew with an A patient suffers a diabetic emergency She is treated by the local EMS crew with an IV an ampule of D50 and transported to the closet hospital despite family members IV an ampule of D50 and transported to the closet hospital despite family members telling you that the patient does not go theretelling you that the patient does not go there
Transport is uneventful and care is turned over to the ED Nurse with a quick verbal Transport is uneventful and care is turned over to the ED Nurse with a quick verbal reportreport
An hour later a private ambulance is called to transport the patient to her desired An hour later a private ambulance is called to transport the patient to her desired hospital for definitive care They notice the IV has infiltrated and D50 got into her hospital for definitive care They notice the IV has infiltrated and D50 got into her surrounding tissuessurrounding tissues
The patient suffers significant tissue damage which requires a fasciotomy to The patient suffers significant tissue damage which requires a fasciotomy to decompress her hand and forearm She has permanent nerve damage and requires decompress her hand and forearm She has permanent nerve damage and requires skin graftingskin grafting
Who get invited to the lawsuit partyWho get invited to the lawsuit party
Depends on the documentation from everyone Depends on the documentation from everyone involved in patient careinvolved in patient care
DocumentationDocumentation
ldquoldquoIf you didnrsquot write it on your patient If you didnrsquot write it on your patient care report you didnrsquot do itrdquocare report you didnrsquot do itrdquo
ObjectivesObjectives Importance of DocumentationImportance of Documentation Identify Data on the PCRIdentify Data on the PCR Types of Documentation FormatsTypes of Documentation Formats Consequences for Poor DocumentationConsequences for Poor Documentation Special ConsiderationsSpecial Considerations Grammar and PunctuationsGrammar and Punctuations Electronic Reporting and WARDSElectronic Reporting and WARDS
Why so ImportantWhy so Important
Permanent part of Permanent part of the patients the patients medical recordmedical record
Written Proof that Written Proof that you did somethingyou did something
Written TestimonyWritten Testimony Quality Assurance Quality Assurance Operations Operations ResearchResearch
ldquoThe content and completeness of the pre-hospital care report directly affects the lawyerrsquos impression of the incident and influences his decision of whether or not to file a lawsuitrdquo
Richard A Lazar JD
Elements of the PCRElements of the PCR Date of the RunDate of the Run Type of callType of call TIMESTIMES
ReceivedReceived EnrouteEnroute SceneScene Patient ContactPatient Contact TransportTransport DestinationDestination
Medical HistoryMedical History AllergiesAllergies MedicationsMedications Chief ComplaintChief Complaint Trauma Trauma
MechanismMechanism Safety Safety
EquipmentEquipment
Vital signsVital signs Blood Blood
PressurePressure PulsePulse RespirationsRespirations Lung SoundsLung Sounds Cap refillCap refill Blood Blood
GlucoseGlucose PupilsPupils
OrganizationOrganization
S O A PS O A P CHARTCHART CHRONOLOGICAL CHRONOLOGICAL
SOAPSOAP
What happenedWhat happened What did you What did you
findfind What do you What do you
thinkthink What did you doWhat did you do
(S) (Subjective) What happened(S) (Subjective) What happened
Medic 27 responded emergent on a 39 year old female who had a syncope from the standing position Patient reports that she
was at a party when she began to feel nauseous Walked into back room and then
passed out on floor Witnesses report patient slumped forward on to a couch and then slid
backward to a carpeted floor Patient also reports that she recalls waking up on floor feeling cold and shivering Patient moved to bed with assistance A bystander called 911
for assistance
(O) (Objective) What did you find(O) (Objective) What did you find
Upon initial contact patient laying in bed in Upon initial contact patient laying in bed in bedroom Alert and oriented to name place bedroom Alert and oriented to name place
time and event Skin warm and dry with time and event Skin warm and dry with normal color and tone Mild muscle tremors normal color and tone Mild muscle tremors
(shivers) in arms and legs Patient does (shivers) in arms and legs Patient does report feeling cold Head normocephalic report feeling cold Head normocephalic without abnormality on visualization or without abnormality on visualization or
palpation Neck midline and intact without palpation Neck midline and intact without pain on palpation or movement Thoracic pain on palpation or movement Thoracic
lumbar and sacral spine intact without pain lumbar and sacral spine intact without pain on palpation or spontaneous movementon palpation or spontaneous movement
My WayMy Way
Level of ConsciousnessLevel of Consciousness Airway Breathing CirculationAirway Breathing Circulation Skin color and tempSkin color and temp Head to Toe ExamHead to Toe Exam Pertinent NegativePertinent Negative
(A) Assessment (What do you think)(A) Assessment (What do you think)
Patient transported to Hospital with seizure Patient transported to Hospital with seizure like activitylike activity
Not a diagnosisNot a diagnosis
Protocol FollowedProtocol Followed
(P) Plan What did you do(P) Plan What did you do
Patient transported non-emergent to Aurora Patient transported non-emergent to Aurora Medical Center emergency room Patient Medical Center emergency room Patient transported without change in status or transported without change in status or
level of consciousness Patients treatment level of consciousness Patients treatment plan included full secondary assessment plan included full secondary assessment detailed neurological examination vital detailed neurological examination vital
signs cardiac monitoring pulse oximetry signs cardiac monitoring pulse oximetry and supplemental oxygen Following hand and supplemental oxygen Following hand off report to staff patient left in hospital off report to staff patient left in hospital bed with rails up and staff in attendancebed with rails up and staff in attendance
C H A R TC H A R T
Chief ComplaintChief Complaint HistoryHistory AllergiesAllergies Rx-TreatmentRx-Treatment TransportTransport
(C) Chief Complaint(C) Chief Complaint
Medic 27 responded emergent on a 39 year old female who had a syncope from the standing position
(H) History Present Illness(H) History Present Illness
HPI (history of present illnessinjury) PMH (past medical history) PQRST AMPLE MOI Onset Signs and Symptoms
(A) Assessment(A) Assessment
Include both negative and positive findings Responses the patient has to your
assessment such as the presence or lack of pain andor the presence or lack of sensation
Diagnostic Testing ECG Pulse Oximetry Capnography Blood Glucose Monitoring
(R) Rx-Treatment(R) Rx-Treatment
Document your treatmentDocument your treatment Responses from the Patient to RxResponses from the Patient to Rx Changes in Patients conditionChanges in Patients condition
Example Example ldquoPain decreased to 510 from ldquoPain decreased to 510 from 710 after NTG administered710 after NTG administered
(T) Transport(T) Transport
Where did you goWhere did you go Change in condition during Change in condition during
transporttransport Alteration from ProtocolAlteration from Protocol Who did you turn care over to Who did you turn care over to
(Name if Possible) Ie RN Robinson(Name if Possible) Ie RN Robinson Patency of airway and IV fluidsPatency of airway and IV fluids
CHRONOLOGICALCHRONOLOGICAL
ldquoldquoWrite like your brain thinks itrdquoWrite like your brain thinks itrdquo
Dispatched non-emergent to University Hospitals Dispatched non-emergent to University Hospitals Emergency Educations center for a transport to Emergency Educations center for a transport to UW ER Arrived on floor and met by staff who UW ER Arrived on floor and met by staff who advised us that the patient was suffering from advised us that the patient was suffering from severe PES (Paramedic Education Syndrome) severe PES (Paramedic Education Syndrome) Patient is Mr D a 48 yo male with hx of PES and Patient is Mr D a 48 yo male with hx of PES and CHF who presented with chest pain and CHF who presented with chest pain and dyspneahellipdyspneahellip
Errors and FalsificationsErrors and Falsifications
Avoid ErrorsAvoid Errors Admit when you made a mistakeAdmit when you made a mistake
Revise if necessaryRevise if necessary Note date and time of revisionNote date and time of revision Keep original documentKeep original document Include purpose of the revisionInclude purpose of the revision Only the original author can make the Only the original author can make the
correctioncorrection
Errors and FalsificationsErrors and Falsifications
Always be honest and through in your Always be honest and through in your documentationdocumentation
CorrectionsCorrections Add a supplement on electronic reportsAdd a supplement on electronic reports One line across the error initial the One line across the error initial the
mistake and make the corrections on mistake and make the corrections on written reportswritten reports
Complete reports as soon as possible Complete reports as soon as possible Lost reports have HUGE legal implicationsLost reports have HUGE legal implications Dont keep copies of your reportsDont keep copies of your reports
HIPPAHIPPA
What Happens on What Happens on the Ambulance the Ambulance stays on the stays on the ambulance ambulance
Health Health InsuranceInsurance PortabilityPortability PrivacyPrivacy AccountabilityAccountability
HIPPAHIPPA
Protects the security and privacy of Protects the security and privacy of all medical records and other health all medical records and other health information used or shared in any information used or shared in any formform
Protects patients rights by giving Protects patients rights by giving access to health information and access to health information and control over how it is usedcontrol over how it is used
PHIPHI Protected Heath InformationProtected Heath Information
Information that relates toInformation that relates to The health of an individualThe health of an individual Health care provided to that individualHealth care provided to that individual Payment of heath care providedPayment of heath care provided
What can be sharedWhat can be shared
Health Insurance Company my need Health Insurance Company my need information to process a claiminformation to process a claim
Caregivers involved with direct care Caregivers involved with direct care Quality Assurance when necessaryQuality Assurance when necessary
Special ConsiderationsSpecial Considerations
Exposure and InjuryExposure and Injury Mass CasualtyMass Casualty Interfacility TransportsInterfacility Transports RefusalsRefusals
Mass Casualty EventsMass Casualty Events
Documentation may have to be Documentation may have to be postponedpostponed
Follow Local Policy and ProcedureFollow Local Policy and Procedure Comprehensive run report must be Comprehensive run report must be
completed for each patient when completed for each patient when time permitstime permits
Refusal of CareRefusal of Care
Potential for LiabilityPotential for Liability Good DocumentationGood Documentation Make it clearMake it clear
Refusal of CareRefusal of Care
The litigation rate for EMS has been steadily increasing
1048657 According to one study patients evaluatedby paramedics but not transported to thehospital account for 50 to 90 of EMSlawsuitsrdquo
1048657 Documentation is your best defenserdquo
DocumentationDocumentation
Physical FindingsPhysical Findings The advice you give the patient about The advice you give the patient about
being transported and the associated being transported and the associated risks for not being transportedrisks for not being transported
Clinical indications that patient is Clinical indications that patient is competent to make a rational decisioncompetent to make a rational decision
Signatures of the patient and witnessSignatures of the patient and witness Full narrativeFull narrative Advise to call 911 if condition changesAdvise to call 911 if condition changes
Do not at any time attempt to talk the patient out of going to the hospital
If you feel strongly that the patient should be seen make every attempt to convince them they should be seen
Donrsquot say lsquo I agree you donrsquot need to gordquo even if you agree
What not to sayWhat not to say
A patient suffers a diabetic emergency She is treated by the local EMS crew with an A patient suffers a diabetic emergency She is treated by the local EMS crew with an IV an ampule of D50 and transported to the closet hospital despite family members IV an ampule of D50 and transported to the closet hospital despite family members telling you that the patient does not go theretelling you that the patient does not go there
Transport is uneventful and care is turned over to the ED Nurse with a quick verbal Transport is uneventful and care is turned over to the ED Nurse with a quick verbal reportreport
An hour later a private ambulance is called to transport the patient to her desired An hour later a private ambulance is called to transport the patient to her desired hospital for definitive care They notice the IV has infiltrated and D50 got into her hospital for definitive care They notice the IV has infiltrated and D50 got into her surrounding tissuessurrounding tissues
The patient suffers significant tissue damage which requires a fasciotomy to The patient suffers significant tissue damage which requires a fasciotomy to decompress her hand and forearm She has permanent nerve damage and requires decompress her hand and forearm She has permanent nerve damage and requires skin graftingskin grafting
Initial Transport Agency-CFDInitial Transport Agency-CFD
First Receiving Hospital-St Anthony HospitalFirst Receiving Hospital-St Anthony Hospital
Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998
Lets Finish upLets Finish up
Be ProfessionalBe Professional AccurateAccurate ConsistentConsistent ThroughThrough ClearClear BriefBrief Paint the PicturePaint the Picture CollaborativeCollaborative
Legible spelling Legible spelling correctcorrect
Tell the TruthTell the Truth Donrsquot duplicate infoDonrsquot duplicate info Follow ProtocolsFollow Protocols Plain LanguagePlain Language Relevant InformationRelevant Information ldquoldquoThe JURYrdquoThe JURYrdquo Have your partner Have your partner
reviewreview
DocumentationDocumentation
ldquoldquoIf you didnrsquot write it on your patient If you didnrsquot write it on your patient care report you didnrsquot do itrdquocare report you didnrsquot do itrdquo
ObjectivesObjectives Importance of DocumentationImportance of Documentation Identify Data on the PCRIdentify Data on the PCR Types of Documentation FormatsTypes of Documentation Formats Consequences for Poor DocumentationConsequences for Poor Documentation Special ConsiderationsSpecial Considerations Grammar and PunctuationsGrammar and Punctuations Electronic Reporting and WARDSElectronic Reporting and WARDS
Why so ImportantWhy so Important
Permanent part of Permanent part of the patients the patients medical recordmedical record
Written Proof that Written Proof that you did somethingyou did something
Written TestimonyWritten Testimony Quality Assurance Quality Assurance Operations Operations ResearchResearch
ldquoThe content and completeness of the pre-hospital care report directly affects the lawyerrsquos impression of the incident and influences his decision of whether or not to file a lawsuitrdquo
Richard A Lazar JD
Elements of the PCRElements of the PCR Date of the RunDate of the Run Type of callType of call TIMESTIMES
ReceivedReceived EnrouteEnroute SceneScene Patient ContactPatient Contact TransportTransport DestinationDestination
Medical HistoryMedical History AllergiesAllergies MedicationsMedications Chief ComplaintChief Complaint Trauma Trauma
MechanismMechanism Safety Safety
EquipmentEquipment
Vital signsVital signs Blood Blood
PressurePressure PulsePulse RespirationsRespirations Lung SoundsLung Sounds Cap refillCap refill Blood Blood
GlucoseGlucose PupilsPupils
OrganizationOrganization
S O A PS O A P CHARTCHART CHRONOLOGICAL CHRONOLOGICAL
SOAPSOAP
What happenedWhat happened What did you What did you
findfind What do you What do you
thinkthink What did you doWhat did you do
(S) (Subjective) What happened(S) (Subjective) What happened
Medic 27 responded emergent on a 39 year old female who had a syncope from the standing position Patient reports that she
was at a party when she began to feel nauseous Walked into back room and then
passed out on floor Witnesses report patient slumped forward on to a couch and then slid
backward to a carpeted floor Patient also reports that she recalls waking up on floor feeling cold and shivering Patient moved to bed with assistance A bystander called 911
for assistance
(O) (Objective) What did you find(O) (Objective) What did you find
Upon initial contact patient laying in bed in Upon initial contact patient laying in bed in bedroom Alert and oriented to name place bedroom Alert and oriented to name place
time and event Skin warm and dry with time and event Skin warm and dry with normal color and tone Mild muscle tremors normal color and tone Mild muscle tremors
(shivers) in arms and legs Patient does (shivers) in arms and legs Patient does report feeling cold Head normocephalic report feeling cold Head normocephalic without abnormality on visualization or without abnormality on visualization or
palpation Neck midline and intact without palpation Neck midline and intact without pain on palpation or movement Thoracic pain on palpation or movement Thoracic
lumbar and sacral spine intact without pain lumbar and sacral spine intact without pain on palpation or spontaneous movementon palpation or spontaneous movement
My WayMy Way
Level of ConsciousnessLevel of Consciousness Airway Breathing CirculationAirway Breathing Circulation Skin color and tempSkin color and temp Head to Toe ExamHead to Toe Exam Pertinent NegativePertinent Negative
(A) Assessment (What do you think)(A) Assessment (What do you think)
Patient transported to Hospital with seizure Patient transported to Hospital with seizure like activitylike activity
Not a diagnosisNot a diagnosis
Protocol FollowedProtocol Followed
(P) Plan What did you do(P) Plan What did you do
Patient transported non-emergent to Aurora Patient transported non-emergent to Aurora Medical Center emergency room Patient Medical Center emergency room Patient transported without change in status or transported without change in status or
level of consciousness Patients treatment level of consciousness Patients treatment plan included full secondary assessment plan included full secondary assessment detailed neurological examination vital detailed neurological examination vital
signs cardiac monitoring pulse oximetry signs cardiac monitoring pulse oximetry and supplemental oxygen Following hand and supplemental oxygen Following hand off report to staff patient left in hospital off report to staff patient left in hospital bed with rails up and staff in attendancebed with rails up and staff in attendance
C H A R TC H A R T
Chief ComplaintChief Complaint HistoryHistory AllergiesAllergies Rx-TreatmentRx-Treatment TransportTransport
(C) Chief Complaint(C) Chief Complaint
Medic 27 responded emergent on a 39 year old female who had a syncope from the standing position
(H) History Present Illness(H) History Present Illness
HPI (history of present illnessinjury) PMH (past medical history) PQRST AMPLE MOI Onset Signs and Symptoms
(A) Assessment(A) Assessment
Include both negative and positive findings Responses the patient has to your
assessment such as the presence or lack of pain andor the presence or lack of sensation
Diagnostic Testing ECG Pulse Oximetry Capnography Blood Glucose Monitoring
(R) Rx-Treatment(R) Rx-Treatment
Document your treatmentDocument your treatment Responses from the Patient to RxResponses from the Patient to Rx Changes in Patients conditionChanges in Patients condition
Example Example ldquoPain decreased to 510 from ldquoPain decreased to 510 from 710 after NTG administered710 after NTG administered
(T) Transport(T) Transport
Where did you goWhere did you go Change in condition during Change in condition during
transporttransport Alteration from ProtocolAlteration from Protocol Who did you turn care over to Who did you turn care over to
(Name if Possible) Ie RN Robinson(Name if Possible) Ie RN Robinson Patency of airway and IV fluidsPatency of airway and IV fluids
CHRONOLOGICALCHRONOLOGICAL
ldquoldquoWrite like your brain thinks itrdquoWrite like your brain thinks itrdquo
Dispatched non-emergent to University Hospitals Dispatched non-emergent to University Hospitals Emergency Educations center for a transport to Emergency Educations center for a transport to UW ER Arrived on floor and met by staff who UW ER Arrived on floor and met by staff who advised us that the patient was suffering from advised us that the patient was suffering from severe PES (Paramedic Education Syndrome) severe PES (Paramedic Education Syndrome) Patient is Mr D a 48 yo male with hx of PES and Patient is Mr D a 48 yo male with hx of PES and CHF who presented with chest pain and CHF who presented with chest pain and dyspneahellipdyspneahellip
Errors and FalsificationsErrors and Falsifications
Avoid ErrorsAvoid Errors Admit when you made a mistakeAdmit when you made a mistake
Revise if necessaryRevise if necessary Note date and time of revisionNote date and time of revision Keep original documentKeep original document Include purpose of the revisionInclude purpose of the revision Only the original author can make the Only the original author can make the
correctioncorrection
Errors and FalsificationsErrors and Falsifications
Always be honest and through in your Always be honest and through in your documentationdocumentation
CorrectionsCorrections Add a supplement on electronic reportsAdd a supplement on electronic reports One line across the error initial the One line across the error initial the
mistake and make the corrections on mistake and make the corrections on written reportswritten reports
Complete reports as soon as possible Complete reports as soon as possible Lost reports have HUGE legal implicationsLost reports have HUGE legal implications Dont keep copies of your reportsDont keep copies of your reports
HIPPAHIPPA
What Happens on What Happens on the Ambulance the Ambulance stays on the stays on the ambulance ambulance
Health Health InsuranceInsurance PortabilityPortability PrivacyPrivacy AccountabilityAccountability
HIPPAHIPPA
Protects the security and privacy of Protects the security and privacy of all medical records and other health all medical records and other health information used or shared in any information used or shared in any formform
Protects patients rights by giving Protects patients rights by giving access to health information and access to health information and control over how it is usedcontrol over how it is used
PHIPHI Protected Heath InformationProtected Heath Information
Information that relates toInformation that relates to The health of an individualThe health of an individual Health care provided to that individualHealth care provided to that individual Payment of heath care providedPayment of heath care provided
What can be sharedWhat can be shared
Health Insurance Company my need Health Insurance Company my need information to process a claiminformation to process a claim
Caregivers involved with direct care Caregivers involved with direct care Quality Assurance when necessaryQuality Assurance when necessary
Special ConsiderationsSpecial Considerations
Exposure and InjuryExposure and Injury Mass CasualtyMass Casualty Interfacility TransportsInterfacility Transports RefusalsRefusals
Mass Casualty EventsMass Casualty Events
Documentation may have to be Documentation may have to be postponedpostponed
Follow Local Policy and ProcedureFollow Local Policy and Procedure Comprehensive run report must be Comprehensive run report must be
completed for each patient when completed for each patient when time permitstime permits
Refusal of CareRefusal of Care
Potential for LiabilityPotential for Liability Good DocumentationGood Documentation Make it clearMake it clear
Refusal of CareRefusal of Care
The litigation rate for EMS has been steadily increasing
1048657 According to one study patients evaluatedby paramedics but not transported to thehospital account for 50 to 90 of EMSlawsuitsrdquo
1048657 Documentation is your best defenserdquo
DocumentationDocumentation
Physical FindingsPhysical Findings The advice you give the patient about The advice you give the patient about
being transported and the associated being transported and the associated risks for not being transportedrisks for not being transported
Clinical indications that patient is Clinical indications that patient is competent to make a rational decisioncompetent to make a rational decision
Signatures of the patient and witnessSignatures of the patient and witness Full narrativeFull narrative Advise to call 911 if condition changesAdvise to call 911 if condition changes
Do not at any time attempt to talk the patient out of going to the hospital
If you feel strongly that the patient should be seen make every attempt to convince them they should be seen
Donrsquot say lsquo I agree you donrsquot need to gordquo even if you agree
What not to sayWhat not to say
A patient suffers a diabetic emergency She is treated by the local EMS crew with an A patient suffers a diabetic emergency She is treated by the local EMS crew with an IV an ampule of D50 and transported to the closet hospital despite family members IV an ampule of D50 and transported to the closet hospital despite family members telling you that the patient does not go theretelling you that the patient does not go there
Transport is uneventful and care is turned over to the ED Nurse with a quick verbal Transport is uneventful and care is turned over to the ED Nurse with a quick verbal reportreport
An hour later a private ambulance is called to transport the patient to her desired An hour later a private ambulance is called to transport the patient to her desired hospital for definitive care They notice the IV has infiltrated and D50 got into her hospital for definitive care They notice the IV has infiltrated and D50 got into her surrounding tissuessurrounding tissues
The patient suffers significant tissue damage which requires a fasciotomy to The patient suffers significant tissue damage which requires a fasciotomy to decompress her hand and forearm She has permanent nerve damage and requires decompress her hand and forearm She has permanent nerve damage and requires skin graftingskin grafting
Initial Transport Agency-CFDInitial Transport Agency-CFD
First Receiving Hospital-St Anthony HospitalFirst Receiving Hospital-St Anthony Hospital
Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998
Lets Finish upLets Finish up
Be ProfessionalBe Professional AccurateAccurate ConsistentConsistent ThroughThrough ClearClear BriefBrief Paint the PicturePaint the Picture CollaborativeCollaborative
Legible spelling Legible spelling correctcorrect
Tell the TruthTell the Truth Donrsquot duplicate infoDonrsquot duplicate info Follow ProtocolsFollow Protocols Plain LanguagePlain Language Relevant InformationRelevant Information ldquoldquoThe JURYrdquoThe JURYrdquo Have your partner Have your partner
reviewreview
ObjectivesObjectives Importance of DocumentationImportance of Documentation Identify Data on the PCRIdentify Data on the PCR Types of Documentation FormatsTypes of Documentation Formats Consequences for Poor DocumentationConsequences for Poor Documentation Special ConsiderationsSpecial Considerations Grammar and PunctuationsGrammar and Punctuations Electronic Reporting and WARDSElectronic Reporting and WARDS
Why so ImportantWhy so Important
Permanent part of Permanent part of the patients the patients medical recordmedical record
Written Proof that Written Proof that you did somethingyou did something
Written TestimonyWritten Testimony Quality Assurance Quality Assurance Operations Operations ResearchResearch
ldquoThe content and completeness of the pre-hospital care report directly affects the lawyerrsquos impression of the incident and influences his decision of whether or not to file a lawsuitrdquo
Richard A Lazar JD
Elements of the PCRElements of the PCR Date of the RunDate of the Run Type of callType of call TIMESTIMES
ReceivedReceived EnrouteEnroute SceneScene Patient ContactPatient Contact TransportTransport DestinationDestination
Medical HistoryMedical History AllergiesAllergies MedicationsMedications Chief ComplaintChief Complaint Trauma Trauma
MechanismMechanism Safety Safety
EquipmentEquipment
Vital signsVital signs Blood Blood
PressurePressure PulsePulse RespirationsRespirations Lung SoundsLung Sounds Cap refillCap refill Blood Blood
GlucoseGlucose PupilsPupils
OrganizationOrganization
S O A PS O A P CHARTCHART CHRONOLOGICAL CHRONOLOGICAL
SOAPSOAP
What happenedWhat happened What did you What did you
findfind What do you What do you
thinkthink What did you doWhat did you do
(S) (Subjective) What happened(S) (Subjective) What happened
Medic 27 responded emergent on a 39 year old female who had a syncope from the standing position Patient reports that she
was at a party when she began to feel nauseous Walked into back room and then
passed out on floor Witnesses report patient slumped forward on to a couch and then slid
backward to a carpeted floor Patient also reports that she recalls waking up on floor feeling cold and shivering Patient moved to bed with assistance A bystander called 911
for assistance
(O) (Objective) What did you find(O) (Objective) What did you find
Upon initial contact patient laying in bed in Upon initial contact patient laying in bed in bedroom Alert and oriented to name place bedroom Alert and oriented to name place
time and event Skin warm and dry with time and event Skin warm and dry with normal color and tone Mild muscle tremors normal color and tone Mild muscle tremors
(shivers) in arms and legs Patient does (shivers) in arms and legs Patient does report feeling cold Head normocephalic report feeling cold Head normocephalic without abnormality on visualization or without abnormality on visualization or
palpation Neck midline and intact without palpation Neck midline and intact without pain on palpation or movement Thoracic pain on palpation or movement Thoracic
lumbar and sacral spine intact without pain lumbar and sacral spine intact without pain on palpation or spontaneous movementon palpation or spontaneous movement
My WayMy Way
Level of ConsciousnessLevel of Consciousness Airway Breathing CirculationAirway Breathing Circulation Skin color and tempSkin color and temp Head to Toe ExamHead to Toe Exam Pertinent NegativePertinent Negative
(A) Assessment (What do you think)(A) Assessment (What do you think)
Patient transported to Hospital with seizure Patient transported to Hospital with seizure like activitylike activity
Not a diagnosisNot a diagnosis
Protocol FollowedProtocol Followed
(P) Plan What did you do(P) Plan What did you do
Patient transported non-emergent to Aurora Patient transported non-emergent to Aurora Medical Center emergency room Patient Medical Center emergency room Patient transported without change in status or transported without change in status or
level of consciousness Patients treatment level of consciousness Patients treatment plan included full secondary assessment plan included full secondary assessment detailed neurological examination vital detailed neurological examination vital
signs cardiac monitoring pulse oximetry signs cardiac monitoring pulse oximetry and supplemental oxygen Following hand and supplemental oxygen Following hand off report to staff patient left in hospital off report to staff patient left in hospital bed with rails up and staff in attendancebed with rails up and staff in attendance
C H A R TC H A R T
Chief ComplaintChief Complaint HistoryHistory AllergiesAllergies Rx-TreatmentRx-Treatment TransportTransport
(C) Chief Complaint(C) Chief Complaint
Medic 27 responded emergent on a 39 year old female who had a syncope from the standing position
(H) History Present Illness(H) History Present Illness
HPI (history of present illnessinjury) PMH (past medical history) PQRST AMPLE MOI Onset Signs and Symptoms
(A) Assessment(A) Assessment
Include both negative and positive findings Responses the patient has to your
assessment such as the presence or lack of pain andor the presence or lack of sensation
Diagnostic Testing ECG Pulse Oximetry Capnography Blood Glucose Monitoring
(R) Rx-Treatment(R) Rx-Treatment
Document your treatmentDocument your treatment Responses from the Patient to RxResponses from the Patient to Rx Changes in Patients conditionChanges in Patients condition
Example Example ldquoPain decreased to 510 from ldquoPain decreased to 510 from 710 after NTG administered710 after NTG administered
(T) Transport(T) Transport
Where did you goWhere did you go Change in condition during Change in condition during
transporttransport Alteration from ProtocolAlteration from Protocol Who did you turn care over to Who did you turn care over to
(Name if Possible) Ie RN Robinson(Name if Possible) Ie RN Robinson Patency of airway and IV fluidsPatency of airway and IV fluids
CHRONOLOGICALCHRONOLOGICAL
ldquoldquoWrite like your brain thinks itrdquoWrite like your brain thinks itrdquo
Dispatched non-emergent to University Hospitals Dispatched non-emergent to University Hospitals Emergency Educations center for a transport to Emergency Educations center for a transport to UW ER Arrived on floor and met by staff who UW ER Arrived on floor and met by staff who advised us that the patient was suffering from advised us that the patient was suffering from severe PES (Paramedic Education Syndrome) severe PES (Paramedic Education Syndrome) Patient is Mr D a 48 yo male with hx of PES and Patient is Mr D a 48 yo male with hx of PES and CHF who presented with chest pain and CHF who presented with chest pain and dyspneahellipdyspneahellip
Errors and FalsificationsErrors and Falsifications
Avoid ErrorsAvoid Errors Admit when you made a mistakeAdmit when you made a mistake
Revise if necessaryRevise if necessary Note date and time of revisionNote date and time of revision Keep original documentKeep original document Include purpose of the revisionInclude purpose of the revision Only the original author can make the Only the original author can make the
correctioncorrection
Errors and FalsificationsErrors and Falsifications
Always be honest and through in your Always be honest and through in your documentationdocumentation
CorrectionsCorrections Add a supplement on electronic reportsAdd a supplement on electronic reports One line across the error initial the One line across the error initial the
mistake and make the corrections on mistake and make the corrections on written reportswritten reports
Complete reports as soon as possible Complete reports as soon as possible Lost reports have HUGE legal implicationsLost reports have HUGE legal implications Dont keep copies of your reportsDont keep copies of your reports
HIPPAHIPPA
What Happens on What Happens on the Ambulance the Ambulance stays on the stays on the ambulance ambulance
Health Health InsuranceInsurance PortabilityPortability PrivacyPrivacy AccountabilityAccountability
HIPPAHIPPA
Protects the security and privacy of Protects the security and privacy of all medical records and other health all medical records and other health information used or shared in any information used or shared in any formform
Protects patients rights by giving Protects patients rights by giving access to health information and access to health information and control over how it is usedcontrol over how it is used
PHIPHI Protected Heath InformationProtected Heath Information
Information that relates toInformation that relates to The health of an individualThe health of an individual Health care provided to that individualHealth care provided to that individual Payment of heath care providedPayment of heath care provided
What can be sharedWhat can be shared
Health Insurance Company my need Health Insurance Company my need information to process a claiminformation to process a claim
Caregivers involved with direct care Caregivers involved with direct care Quality Assurance when necessaryQuality Assurance when necessary
Special ConsiderationsSpecial Considerations
Exposure and InjuryExposure and Injury Mass CasualtyMass Casualty Interfacility TransportsInterfacility Transports RefusalsRefusals
Mass Casualty EventsMass Casualty Events
Documentation may have to be Documentation may have to be postponedpostponed
Follow Local Policy and ProcedureFollow Local Policy and Procedure Comprehensive run report must be Comprehensive run report must be
completed for each patient when completed for each patient when time permitstime permits
Refusal of CareRefusal of Care
Potential for LiabilityPotential for Liability Good DocumentationGood Documentation Make it clearMake it clear
Refusal of CareRefusal of Care
The litigation rate for EMS has been steadily increasing
1048657 According to one study patients evaluatedby paramedics but not transported to thehospital account for 50 to 90 of EMSlawsuitsrdquo
1048657 Documentation is your best defenserdquo
DocumentationDocumentation
Physical FindingsPhysical Findings The advice you give the patient about The advice you give the patient about
being transported and the associated being transported and the associated risks for not being transportedrisks for not being transported
Clinical indications that patient is Clinical indications that patient is competent to make a rational decisioncompetent to make a rational decision
Signatures of the patient and witnessSignatures of the patient and witness Full narrativeFull narrative Advise to call 911 if condition changesAdvise to call 911 if condition changes
Do not at any time attempt to talk the patient out of going to the hospital
If you feel strongly that the patient should be seen make every attempt to convince them they should be seen
Donrsquot say lsquo I agree you donrsquot need to gordquo even if you agree
What not to sayWhat not to say
A patient suffers a diabetic emergency She is treated by the local EMS crew with an A patient suffers a diabetic emergency She is treated by the local EMS crew with an IV an ampule of D50 and transported to the closet hospital despite family members IV an ampule of D50 and transported to the closet hospital despite family members telling you that the patient does not go theretelling you that the patient does not go there
Transport is uneventful and care is turned over to the ED Nurse with a quick verbal Transport is uneventful and care is turned over to the ED Nurse with a quick verbal reportreport
An hour later a private ambulance is called to transport the patient to her desired An hour later a private ambulance is called to transport the patient to her desired hospital for definitive care They notice the IV has infiltrated and D50 got into her hospital for definitive care They notice the IV has infiltrated and D50 got into her surrounding tissuessurrounding tissues
The patient suffers significant tissue damage which requires a fasciotomy to The patient suffers significant tissue damage which requires a fasciotomy to decompress her hand and forearm She has permanent nerve damage and requires decompress her hand and forearm She has permanent nerve damage and requires skin graftingskin grafting
Initial Transport Agency-CFDInitial Transport Agency-CFD
First Receiving Hospital-St Anthony HospitalFirst Receiving Hospital-St Anthony Hospital
Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998
Lets Finish upLets Finish up
Be ProfessionalBe Professional AccurateAccurate ConsistentConsistent ThroughThrough ClearClear BriefBrief Paint the PicturePaint the Picture CollaborativeCollaborative
Legible spelling Legible spelling correctcorrect
Tell the TruthTell the Truth Donrsquot duplicate infoDonrsquot duplicate info Follow ProtocolsFollow Protocols Plain LanguagePlain Language Relevant InformationRelevant Information ldquoldquoThe JURYrdquoThe JURYrdquo Have your partner Have your partner
reviewreview
Why so ImportantWhy so Important
Permanent part of Permanent part of the patients the patients medical recordmedical record
Written Proof that Written Proof that you did somethingyou did something
Written TestimonyWritten Testimony Quality Assurance Quality Assurance Operations Operations ResearchResearch
ldquoThe content and completeness of the pre-hospital care report directly affects the lawyerrsquos impression of the incident and influences his decision of whether or not to file a lawsuitrdquo
Richard A Lazar JD
Elements of the PCRElements of the PCR Date of the RunDate of the Run Type of callType of call TIMESTIMES
ReceivedReceived EnrouteEnroute SceneScene Patient ContactPatient Contact TransportTransport DestinationDestination
Medical HistoryMedical History AllergiesAllergies MedicationsMedications Chief ComplaintChief Complaint Trauma Trauma
MechanismMechanism Safety Safety
EquipmentEquipment
Vital signsVital signs Blood Blood
PressurePressure PulsePulse RespirationsRespirations Lung SoundsLung Sounds Cap refillCap refill Blood Blood
GlucoseGlucose PupilsPupils
OrganizationOrganization
S O A PS O A P CHARTCHART CHRONOLOGICAL CHRONOLOGICAL
SOAPSOAP
What happenedWhat happened What did you What did you
findfind What do you What do you
thinkthink What did you doWhat did you do
(S) (Subjective) What happened(S) (Subjective) What happened
Medic 27 responded emergent on a 39 year old female who had a syncope from the standing position Patient reports that she
was at a party when she began to feel nauseous Walked into back room and then
passed out on floor Witnesses report patient slumped forward on to a couch and then slid
backward to a carpeted floor Patient also reports that she recalls waking up on floor feeling cold and shivering Patient moved to bed with assistance A bystander called 911
for assistance
(O) (Objective) What did you find(O) (Objective) What did you find
Upon initial contact patient laying in bed in Upon initial contact patient laying in bed in bedroom Alert and oriented to name place bedroom Alert and oriented to name place
time and event Skin warm and dry with time and event Skin warm and dry with normal color and tone Mild muscle tremors normal color and tone Mild muscle tremors
(shivers) in arms and legs Patient does (shivers) in arms and legs Patient does report feeling cold Head normocephalic report feeling cold Head normocephalic without abnormality on visualization or without abnormality on visualization or
palpation Neck midline and intact without palpation Neck midline and intact without pain on palpation or movement Thoracic pain on palpation or movement Thoracic
lumbar and sacral spine intact without pain lumbar and sacral spine intact without pain on palpation or spontaneous movementon palpation or spontaneous movement
My WayMy Way
Level of ConsciousnessLevel of Consciousness Airway Breathing CirculationAirway Breathing Circulation Skin color and tempSkin color and temp Head to Toe ExamHead to Toe Exam Pertinent NegativePertinent Negative
(A) Assessment (What do you think)(A) Assessment (What do you think)
Patient transported to Hospital with seizure Patient transported to Hospital with seizure like activitylike activity
Not a diagnosisNot a diagnosis
Protocol FollowedProtocol Followed
(P) Plan What did you do(P) Plan What did you do
Patient transported non-emergent to Aurora Patient transported non-emergent to Aurora Medical Center emergency room Patient Medical Center emergency room Patient transported without change in status or transported without change in status or
level of consciousness Patients treatment level of consciousness Patients treatment plan included full secondary assessment plan included full secondary assessment detailed neurological examination vital detailed neurological examination vital
signs cardiac monitoring pulse oximetry signs cardiac monitoring pulse oximetry and supplemental oxygen Following hand and supplemental oxygen Following hand off report to staff patient left in hospital off report to staff patient left in hospital bed with rails up and staff in attendancebed with rails up and staff in attendance
C H A R TC H A R T
Chief ComplaintChief Complaint HistoryHistory AllergiesAllergies Rx-TreatmentRx-Treatment TransportTransport
(C) Chief Complaint(C) Chief Complaint
Medic 27 responded emergent on a 39 year old female who had a syncope from the standing position
(H) History Present Illness(H) History Present Illness
HPI (history of present illnessinjury) PMH (past medical history) PQRST AMPLE MOI Onset Signs and Symptoms
(A) Assessment(A) Assessment
Include both negative and positive findings Responses the patient has to your
assessment such as the presence or lack of pain andor the presence or lack of sensation
Diagnostic Testing ECG Pulse Oximetry Capnography Blood Glucose Monitoring
(R) Rx-Treatment(R) Rx-Treatment
Document your treatmentDocument your treatment Responses from the Patient to RxResponses from the Patient to Rx Changes in Patients conditionChanges in Patients condition
Example Example ldquoPain decreased to 510 from ldquoPain decreased to 510 from 710 after NTG administered710 after NTG administered
(T) Transport(T) Transport
Where did you goWhere did you go Change in condition during Change in condition during
transporttransport Alteration from ProtocolAlteration from Protocol Who did you turn care over to Who did you turn care over to
(Name if Possible) Ie RN Robinson(Name if Possible) Ie RN Robinson Patency of airway and IV fluidsPatency of airway and IV fluids
CHRONOLOGICALCHRONOLOGICAL
ldquoldquoWrite like your brain thinks itrdquoWrite like your brain thinks itrdquo
Dispatched non-emergent to University Hospitals Dispatched non-emergent to University Hospitals Emergency Educations center for a transport to Emergency Educations center for a transport to UW ER Arrived on floor and met by staff who UW ER Arrived on floor and met by staff who advised us that the patient was suffering from advised us that the patient was suffering from severe PES (Paramedic Education Syndrome) severe PES (Paramedic Education Syndrome) Patient is Mr D a 48 yo male with hx of PES and Patient is Mr D a 48 yo male with hx of PES and CHF who presented with chest pain and CHF who presented with chest pain and dyspneahellipdyspneahellip
Errors and FalsificationsErrors and Falsifications
Avoid ErrorsAvoid Errors Admit when you made a mistakeAdmit when you made a mistake
Revise if necessaryRevise if necessary Note date and time of revisionNote date and time of revision Keep original documentKeep original document Include purpose of the revisionInclude purpose of the revision Only the original author can make the Only the original author can make the
correctioncorrection
Errors and FalsificationsErrors and Falsifications
Always be honest and through in your Always be honest and through in your documentationdocumentation
CorrectionsCorrections Add a supplement on electronic reportsAdd a supplement on electronic reports One line across the error initial the One line across the error initial the
mistake and make the corrections on mistake and make the corrections on written reportswritten reports
Complete reports as soon as possible Complete reports as soon as possible Lost reports have HUGE legal implicationsLost reports have HUGE legal implications Dont keep copies of your reportsDont keep copies of your reports
HIPPAHIPPA
What Happens on What Happens on the Ambulance the Ambulance stays on the stays on the ambulance ambulance
Health Health InsuranceInsurance PortabilityPortability PrivacyPrivacy AccountabilityAccountability
HIPPAHIPPA
Protects the security and privacy of Protects the security and privacy of all medical records and other health all medical records and other health information used or shared in any information used or shared in any formform
Protects patients rights by giving Protects patients rights by giving access to health information and access to health information and control over how it is usedcontrol over how it is used
PHIPHI Protected Heath InformationProtected Heath Information
Information that relates toInformation that relates to The health of an individualThe health of an individual Health care provided to that individualHealth care provided to that individual Payment of heath care providedPayment of heath care provided
What can be sharedWhat can be shared
Health Insurance Company my need Health Insurance Company my need information to process a claiminformation to process a claim
Caregivers involved with direct care Caregivers involved with direct care Quality Assurance when necessaryQuality Assurance when necessary
Special ConsiderationsSpecial Considerations
Exposure and InjuryExposure and Injury Mass CasualtyMass Casualty Interfacility TransportsInterfacility Transports RefusalsRefusals
Mass Casualty EventsMass Casualty Events
Documentation may have to be Documentation may have to be postponedpostponed
Follow Local Policy and ProcedureFollow Local Policy and Procedure Comprehensive run report must be Comprehensive run report must be
completed for each patient when completed for each patient when time permitstime permits
Refusal of CareRefusal of Care
Potential for LiabilityPotential for Liability Good DocumentationGood Documentation Make it clearMake it clear
Refusal of CareRefusal of Care
The litigation rate for EMS has been steadily increasing
1048657 According to one study patients evaluatedby paramedics but not transported to thehospital account for 50 to 90 of EMSlawsuitsrdquo
1048657 Documentation is your best defenserdquo
DocumentationDocumentation
Physical FindingsPhysical Findings The advice you give the patient about The advice you give the patient about
being transported and the associated being transported and the associated risks for not being transportedrisks for not being transported
Clinical indications that patient is Clinical indications that patient is competent to make a rational decisioncompetent to make a rational decision
Signatures of the patient and witnessSignatures of the patient and witness Full narrativeFull narrative Advise to call 911 if condition changesAdvise to call 911 if condition changes
Do not at any time attempt to talk the patient out of going to the hospital
If you feel strongly that the patient should be seen make every attempt to convince them they should be seen
Donrsquot say lsquo I agree you donrsquot need to gordquo even if you agree
What not to sayWhat not to say
A patient suffers a diabetic emergency She is treated by the local EMS crew with an A patient suffers a diabetic emergency She is treated by the local EMS crew with an IV an ampule of D50 and transported to the closet hospital despite family members IV an ampule of D50 and transported to the closet hospital despite family members telling you that the patient does not go theretelling you that the patient does not go there
Transport is uneventful and care is turned over to the ED Nurse with a quick verbal Transport is uneventful and care is turned over to the ED Nurse with a quick verbal reportreport
An hour later a private ambulance is called to transport the patient to her desired An hour later a private ambulance is called to transport the patient to her desired hospital for definitive care They notice the IV has infiltrated and D50 got into her hospital for definitive care They notice the IV has infiltrated and D50 got into her surrounding tissuessurrounding tissues
The patient suffers significant tissue damage which requires a fasciotomy to The patient suffers significant tissue damage which requires a fasciotomy to decompress her hand and forearm She has permanent nerve damage and requires decompress her hand and forearm She has permanent nerve damage and requires skin graftingskin grafting
Initial Transport Agency-CFDInitial Transport Agency-CFD
First Receiving Hospital-St Anthony HospitalFirst Receiving Hospital-St Anthony Hospital
Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998
Lets Finish upLets Finish up
Be ProfessionalBe Professional AccurateAccurate ConsistentConsistent ThroughThrough ClearClear BriefBrief Paint the PicturePaint the Picture CollaborativeCollaborative
Legible spelling Legible spelling correctcorrect
Tell the TruthTell the Truth Donrsquot duplicate infoDonrsquot duplicate info Follow ProtocolsFollow Protocols Plain LanguagePlain Language Relevant InformationRelevant Information ldquoldquoThe JURYrdquoThe JURYrdquo Have your partner Have your partner
reviewreview
ldquoThe content and completeness of the pre-hospital care report directly affects the lawyerrsquos impression of the incident and influences his decision of whether or not to file a lawsuitrdquo
Richard A Lazar JD
Elements of the PCRElements of the PCR Date of the RunDate of the Run Type of callType of call TIMESTIMES
ReceivedReceived EnrouteEnroute SceneScene Patient ContactPatient Contact TransportTransport DestinationDestination
Medical HistoryMedical History AllergiesAllergies MedicationsMedications Chief ComplaintChief Complaint Trauma Trauma
MechanismMechanism Safety Safety
EquipmentEquipment
Vital signsVital signs Blood Blood
PressurePressure PulsePulse RespirationsRespirations Lung SoundsLung Sounds Cap refillCap refill Blood Blood
GlucoseGlucose PupilsPupils
OrganizationOrganization
S O A PS O A P CHARTCHART CHRONOLOGICAL CHRONOLOGICAL
SOAPSOAP
What happenedWhat happened What did you What did you
findfind What do you What do you
thinkthink What did you doWhat did you do
(S) (Subjective) What happened(S) (Subjective) What happened
Medic 27 responded emergent on a 39 year old female who had a syncope from the standing position Patient reports that she
was at a party when she began to feel nauseous Walked into back room and then
passed out on floor Witnesses report patient slumped forward on to a couch and then slid
backward to a carpeted floor Patient also reports that she recalls waking up on floor feeling cold and shivering Patient moved to bed with assistance A bystander called 911
for assistance
(O) (Objective) What did you find(O) (Objective) What did you find
Upon initial contact patient laying in bed in Upon initial contact patient laying in bed in bedroom Alert and oriented to name place bedroom Alert and oriented to name place
time and event Skin warm and dry with time and event Skin warm and dry with normal color and tone Mild muscle tremors normal color and tone Mild muscle tremors
(shivers) in arms and legs Patient does (shivers) in arms and legs Patient does report feeling cold Head normocephalic report feeling cold Head normocephalic without abnormality on visualization or without abnormality on visualization or
palpation Neck midline and intact without palpation Neck midline and intact without pain on palpation or movement Thoracic pain on palpation or movement Thoracic
lumbar and sacral spine intact without pain lumbar and sacral spine intact without pain on palpation or spontaneous movementon palpation or spontaneous movement
My WayMy Way
Level of ConsciousnessLevel of Consciousness Airway Breathing CirculationAirway Breathing Circulation Skin color and tempSkin color and temp Head to Toe ExamHead to Toe Exam Pertinent NegativePertinent Negative
(A) Assessment (What do you think)(A) Assessment (What do you think)
Patient transported to Hospital with seizure Patient transported to Hospital with seizure like activitylike activity
Not a diagnosisNot a diagnosis
Protocol FollowedProtocol Followed
(P) Plan What did you do(P) Plan What did you do
Patient transported non-emergent to Aurora Patient transported non-emergent to Aurora Medical Center emergency room Patient Medical Center emergency room Patient transported without change in status or transported without change in status or
level of consciousness Patients treatment level of consciousness Patients treatment plan included full secondary assessment plan included full secondary assessment detailed neurological examination vital detailed neurological examination vital
signs cardiac monitoring pulse oximetry signs cardiac monitoring pulse oximetry and supplemental oxygen Following hand and supplemental oxygen Following hand off report to staff patient left in hospital off report to staff patient left in hospital bed with rails up and staff in attendancebed with rails up and staff in attendance
C H A R TC H A R T
Chief ComplaintChief Complaint HistoryHistory AllergiesAllergies Rx-TreatmentRx-Treatment TransportTransport
(C) Chief Complaint(C) Chief Complaint
Medic 27 responded emergent on a 39 year old female who had a syncope from the standing position
(H) History Present Illness(H) History Present Illness
HPI (history of present illnessinjury) PMH (past medical history) PQRST AMPLE MOI Onset Signs and Symptoms
(A) Assessment(A) Assessment
Include both negative and positive findings Responses the patient has to your
assessment such as the presence or lack of pain andor the presence or lack of sensation
Diagnostic Testing ECG Pulse Oximetry Capnography Blood Glucose Monitoring
(R) Rx-Treatment(R) Rx-Treatment
Document your treatmentDocument your treatment Responses from the Patient to RxResponses from the Patient to Rx Changes in Patients conditionChanges in Patients condition
Example Example ldquoPain decreased to 510 from ldquoPain decreased to 510 from 710 after NTG administered710 after NTG administered
(T) Transport(T) Transport
Where did you goWhere did you go Change in condition during Change in condition during
transporttransport Alteration from ProtocolAlteration from Protocol Who did you turn care over to Who did you turn care over to
(Name if Possible) Ie RN Robinson(Name if Possible) Ie RN Robinson Patency of airway and IV fluidsPatency of airway and IV fluids
CHRONOLOGICALCHRONOLOGICAL
ldquoldquoWrite like your brain thinks itrdquoWrite like your brain thinks itrdquo
Dispatched non-emergent to University Hospitals Dispatched non-emergent to University Hospitals Emergency Educations center for a transport to Emergency Educations center for a transport to UW ER Arrived on floor and met by staff who UW ER Arrived on floor and met by staff who advised us that the patient was suffering from advised us that the patient was suffering from severe PES (Paramedic Education Syndrome) severe PES (Paramedic Education Syndrome) Patient is Mr D a 48 yo male with hx of PES and Patient is Mr D a 48 yo male with hx of PES and CHF who presented with chest pain and CHF who presented with chest pain and dyspneahellipdyspneahellip
Errors and FalsificationsErrors and Falsifications
Avoid ErrorsAvoid Errors Admit when you made a mistakeAdmit when you made a mistake
Revise if necessaryRevise if necessary Note date and time of revisionNote date and time of revision Keep original documentKeep original document Include purpose of the revisionInclude purpose of the revision Only the original author can make the Only the original author can make the
correctioncorrection
Errors and FalsificationsErrors and Falsifications
Always be honest and through in your Always be honest and through in your documentationdocumentation
CorrectionsCorrections Add a supplement on electronic reportsAdd a supplement on electronic reports One line across the error initial the One line across the error initial the
mistake and make the corrections on mistake and make the corrections on written reportswritten reports
Complete reports as soon as possible Complete reports as soon as possible Lost reports have HUGE legal implicationsLost reports have HUGE legal implications Dont keep copies of your reportsDont keep copies of your reports
HIPPAHIPPA
What Happens on What Happens on the Ambulance the Ambulance stays on the stays on the ambulance ambulance
Health Health InsuranceInsurance PortabilityPortability PrivacyPrivacy AccountabilityAccountability
HIPPAHIPPA
Protects the security and privacy of Protects the security and privacy of all medical records and other health all medical records and other health information used or shared in any information used or shared in any formform
Protects patients rights by giving Protects patients rights by giving access to health information and access to health information and control over how it is usedcontrol over how it is used
PHIPHI Protected Heath InformationProtected Heath Information
Information that relates toInformation that relates to The health of an individualThe health of an individual Health care provided to that individualHealth care provided to that individual Payment of heath care providedPayment of heath care provided
What can be sharedWhat can be shared
Health Insurance Company my need Health Insurance Company my need information to process a claiminformation to process a claim
Caregivers involved with direct care Caregivers involved with direct care Quality Assurance when necessaryQuality Assurance when necessary
Special ConsiderationsSpecial Considerations
Exposure and InjuryExposure and Injury Mass CasualtyMass Casualty Interfacility TransportsInterfacility Transports RefusalsRefusals
Mass Casualty EventsMass Casualty Events
Documentation may have to be Documentation may have to be postponedpostponed
Follow Local Policy and ProcedureFollow Local Policy and Procedure Comprehensive run report must be Comprehensive run report must be
completed for each patient when completed for each patient when time permitstime permits
Refusal of CareRefusal of Care
Potential for LiabilityPotential for Liability Good DocumentationGood Documentation Make it clearMake it clear
Refusal of CareRefusal of Care
The litigation rate for EMS has been steadily increasing
1048657 According to one study patients evaluatedby paramedics but not transported to thehospital account for 50 to 90 of EMSlawsuitsrdquo
1048657 Documentation is your best defenserdquo
DocumentationDocumentation
Physical FindingsPhysical Findings The advice you give the patient about The advice you give the patient about
being transported and the associated being transported and the associated risks for not being transportedrisks for not being transported
Clinical indications that patient is Clinical indications that patient is competent to make a rational decisioncompetent to make a rational decision
Signatures of the patient and witnessSignatures of the patient and witness Full narrativeFull narrative Advise to call 911 if condition changesAdvise to call 911 if condition changes
Do not at any time attempt to talk the patient out of going to the hospital
If you feel strongly that the patient should be seen make every attempt to convince them they should be seen
Donrsquot say lsquo I agree you donrsquot need to gordquo even if you agree
What not to sayWhat not to say
A patient suffers a diabetic emergency She is treated by the local EMS crew with an A patient suffers a diabetic emergency She is treated by the local EMS crew with an IV an ampule of D50 and transported to the closet hospital despite family members IV an ampule of D50 and transported to the closet hospital despite family members telling you that the patient does not go theretelling you that the patient does not go there
Transport is uneventful and care is turned over to the ED Nurse with a quick verbal Transport is uneventful and care is turned over to the ED Nurse with a quick verbal reportreport
An hour later a private ambulance is called to transport the patient to her desired An hour later a private ambulance is called to transport the patient to her desired hospital for definitive care They notice the IV has infiltrated and D50 got into her hospital for definitive care They notice the IV has infiltrated and D50 got into her surrounding tissuessurrounding tissues
The patient suffers significant tissue damage which requires a fasciotomy to The patient suffers significant tissue damage which requires a fasciotomy to decompress her hand and forearm She has permanent nerve damage and requires decompress her hand and forearm She has permanent nerve damage and requires skin graftingskin grafting
Initial Transport Agency-CFDInitial Transport Agency-CFD
First Receiving Hospital-St Anthony HospitalFirst Receiving Hospital-St Anthony Hospital
Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998
Lets Finish upLets Finish up
Be ProfessionalBe Professional AccurateAccurate ConsistentConsistent ThroughThrough ClearClear BriefBrief Paint the PicturePaint the Picture CollaborativeCollaborative
Legible spelling Legible spelling correctcorrect
Tell the TruthTell the Truth Donrsquot duplicate infoDonrsquot duplicate info Follow ProtocolsFollow Protocols Plain LanguagePlain Language Relevant InformationRelevant Information ldquoldquoThe JURYrdquoThe JURYrdquo Have your partner Have your partner
reviewreview
Elements of the PCRElements of the PCR Date of the RunDate of the Run Type of callType of call TIMESTIMES
ReceivedReceived EnrouteEnroute SceneScene Patient ContactPatient Contact TransportTransport DestinationDestination
Medical HistoryMedical History AllergiesAllergies MedicationsMedications Chief ComplaintChief Complaint Trauma Trauma
MechanismMechanism Safety Safety
EquipmentEquipment
Vital signsVital signs Blood Blood
PressurePressure PulsePulse RespirationsRespirations Lung SoundsLung Sounds Cap refillCap refill Blood Blood
GlucoseGlucose PupilsPupils
OrganizationOrganization
S O A PS O A P CHARTCHART CHRONOLOGICAL CHRONOLOGICAL
SOAPSOAP
What happenedWhat happened What did you What did you
findfind What do you What do you
thinkthink What did you doWhat did you do
(S) (Subjective) What happened(S) (Subjective) What happened
Medic 27 responded emergent on a 39 year old female who had a syncope from the standing position Patient reports that she
was at a party when she began to feel nauseous Walked into back room and then
passed out on floor Witnesses report patient slumped forward on to a couch and then slid
backward to a carpeted floor Patient also reports that she recalls waking up on floor feeling cold and shivering Patient moved to bed with assistance A bystander called 911
for assistance
(O) (Objective) What did you find(O) (Objective) What did you find
Upon initial contact patient laying in bed in Upon initial contact patient laying in bed in bedroom Alert and oriented to name place bedroom Alert and oriented to name place
time and event Skin warm and dry with time and event Skin warm and dry with normal color and tone Mild muscle tremors normal color and tone Mild muscle tremors
(shivers) in arms and legs Patient does (shivers) in arms and legs Patient does report feeling cold Head normocephalic report feeling cold Head normocephalic without abnormality on visualization or without abnormality on visualization or
palpation Neck midline and intact without palpation Neck midline and intact without pain on palpation or movement Thoracic pain on palpation or movement Thoracic
lumbar and sacral spine intact without pain lumbar and sacral spine intact without pain on palpation or spontaneous movementon palpation or spontaneous movement
My WayMy Way
Level of ConsciousnessLevel of Consciousness Airway Breathing CirculationAirway Breathing Circulation Skin color and tempSkin color and temp Head to Toe ExamHead to Toe Exam Pertinent NegativePertinent Negative
(A) Assessment (What do you think)(A) Assessment (What do you think)
Patient transported to Hospital with seizure Patient transported to Hospital with seizure like activitylike activity
Not a diagnosisNot a diagnosis
Protocol FollowedProtocol Followed
(P) Plan What did you do(P) Plan What did you do
Patient transported non-emergent to Aurora Patient transported non-emergent to Aurora Medical Center emergency room Patient Medical Center emergency room Patient transported without change in status or transported without change in status or
level of consciousness Patients treatment level of consciousness Patients treatment plan included full secondary assessment plan included full secondary assessment detailed neurological examination vital detailed neurological examination vital
signs cardiac monitoring pulse oximetry signs cardiac monitoring pulse oximetry and supplemental oxygen Following hand and supplemental oxygen Following hand off report to staff patient left in hospital off report to staff patient left in hospital bed with rails up and staff in attendancebed with rails up and staff in attendance
C H A R TC H A R T
Chief ComplaintChief Complaint HistoryHistory AllergiesAllergies Rx-TreatmentRx-Treatment TransportTransport
(C) Chief Complaint(C) Chief Complaint
Medic 27 responded emergent on a 39 year old female who had a syncope from the standing position
(H) History Present Illness(H) History Present Illness
HPI (history of present illnessinjury) PMH (past medical history) PQRST AMPLE MOI Onset Signs and Symptoms
(A) Assessment(A) Assessment
Include both negative and positive findings Responses the patient has to your
assessment such as the presence or lack of pain andor the presence or lack of sensation
Diagnostic Testing ECG Pulse Oximetry Capnography Blood Glucose Monitoring
(R) Rx-Treatment(R) Rx-Treatment
Document your treatmentDocument your treatment Responses from the Patient to RxResponses from the Patient to Rx Changes in Patients conditionChanges in Patients condition
Example Example ldquoPain decreased to 510 from ldquoPain decreased to 510 from 710 after NTG administered710 after NTG administered
(T) Transport(T) Transport
Where did you goWhere did you go Change in condition during Change in condition during
transporttransport Alteration from ProtocolAlteration from Protocol Who did you turn care over to Who did you turn care over to
(Name if Possible) Ie RN Robinson(Name if Possible) Ie RN Robinson Patency of airway and IV fluidsPatency of airway and IV fluids
CHRONOLOGICALCHRONOLOGICAL
ldquoldquoWrite like your brain thinks itrdquoWrite like your brain thinks itrdquo
Dispatched non-emergent to University Hospitals Dispatched non-emergent to University Hospitals Emergency Educations center for a transport to Emergency Educations center for a transport to UW ER Arrived on floor and met by staff who UW ER Arrived on floor and met by staff who advised us that the patient was suffering from advised us that the patient was suffering from severe PES (Paramedic Education Syndrome) severe PES (Paramedic Education Syndrome) Patient is Mr D a 48 yo male with hx of PES and Patient is Mr D a 48 yo male with hx of PES and CHF who presented with chest pain and CHF who presented with chest pain and dyspneahellipdyspneahellip
Errors and FalsificationsErrors and Falsifications
Avoid ErrorsAvoid Errors Admit when you made a mistakeAdmit when you made a mistake
Revise if necessaryRevise if necessary Note date and time of revisionNote date and time of revision Keep original documentKeep original document Include purpose of the revisionInclude purpose of the revision Only the original author can make the Only the original author can make the
correctioncorrection
Errors and FalsificationsErrors and Falsifications
Always be honest and through in your Always be honest and through in your documentationdocumentation
CorrectionsCorrections Add a supplement on electronic reportsAdd a supplement on electronic reports One line across the error initial the One line across the error initial the
mistake and make the corrections on mistake and make the corrections on written reportswritten reports
Complete reports as soon as possible Complete reports as soon as possible Lost reports have HUGE legal implicationsLost reports have HUGE legal implications Dont keep copies of your reportsDont keep copies of your reports
HIPPAHIPPA
What Happens on What Happens on the Ambulance the Ambulance stays on the stays on the ambulance ambulance
Health Health InsuranceInsurance PortabilityPortability PrivacyPrivacy AccountabilityAccountability
HIPPAHIPPA
Protects the security and privacy of Protects the security and privacy of all medical records and other health all medical records and other health information used or shared in any information used or shared in any formform
Protects patients rights by giving Protects patients rights by giving access to health information and access to health information and control over how it is usedcontrol over how it is used
PHIPHI Protected Heath InformationProtected Heath Information
Information that relates toInformation that relates to The health of an individualThe health of an individual Health care provided to that individualHealth care provided to that individual Payment of heath care providedPayment of heath care provided
What can be sharedWhat can be shared
Health Insurance Company my need Health Insurance Company my need information to process a claiminformation to process a claim
Caregivers involved with direct care Caregivers involved with direct care Quality Assurance when necessaryQuality Assurance when necessary
Special ConsiderationsSpecial Considerations
Exposure and InjuryExposure and Injury Mass CasualtyMass Casualty Interfacility TransportsInterfacility Transports RefusalsRefusals
Mass Casualty EventsMass Casualty Events
Documentation may have to be Documentation may have to be postponedpostponed
Follow Local Policy and ProcedureFollow Local Policy and Procedure Comprehensive run report must be Comprehensive run report must be
completed for each patient when completed for each patient when time permitstime permits
Refusal of CareRefusal of Care
Potential for LiabilityPotential for Liability Good DocumentationGood Documentation Make it clearMake it clear
Refusal of CareRefusal of Care
The litigation rate for EMS has been steadily increasing
1048657 According to one study patients evaluatedby paramedics but not transported to thehospital account for 50 to 90 of EMSlawsuitsrdquo
1048657 Documentation is your best defenserdquo
DocumentationDocumentation
Physical FindingsPhysical Findings The advice you give the patient about The advice you give the patient about
being transported and the associated being transported and the associated risks for not being transportedrisks for not being transported
Clinical indications that patient is Clinical indications that patient is competent to make a rational decisioncompetent to make a rational decision
Signatures of the patient and witnessSignatures of the patient and witness Full narrativeFull narrative Advise to call 911 if condition changesAdvise to call 911 if condition changes
Do not at any time attempt to talk the patient out of going to the hospital
If you feel strongly that the patient should be seen make every attempt to convince them they should be seen
Donrsquot say lsquo I agree you donrsquot need to gordquo even if you agree
What not to sayWhat not to say
A patient suffers a diabetic emergency She is treated by the local EMS crew with an A patient suffers a diabetic emergency She is treated by the local EMS crew with an IV an ampule of D50 and transported to the closet hospital despite family members IV an ampule of D50 and transported to the closet hospital despite family members telling you that the patient does not go theretelling you that the patient does not go there
Transport is uneventful and care is turned over to the ED Nurse with a quick verbal Transport is uneventful and care is turned over to the ED Nurse with a quick verbal reportreport
An hour later a private ambulance is called to transport the patient to her desired An hour later a private ambulance is called to transport the patient to her desired hospital for definitive care They notice the IV has infiltrated and D50 got into her hospital for definitive care They notice the IV has infiltrated and D50 got into her surrounding tissuessurrounding tissues
The patient suffers significant tissue damage which requires a fasciotomy to The patient suffers significant tissue damage which requires a fasciotomy to decompress her hand and forearm She has permanent nerve damage and requires decompress her hand and forearm She has permanent nerve damage and requires skin graftingskin grafting
Initial Transport Agency-CFDInitial Transport Agency-CFD
First Receiving Hospital-St Anthony HospitalFirst Receiving Hospital-St Anthony Hospital
Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998
Lets Finish upLets Finish up
Be ProfessionalBe Professional AccurateAccurate ConsistentConsistent ThroughThrough ClearClear BriefBrief Paint the PicturePaint the Picture CollaborativeCollaborative
Legible spelling Legible spelling correctcorrect
Tell the TruthTell the Truth Donrsquot duplicate infoDonrsquot duplicate info Follow ProtocolsFollow Protocols Plain LanguagePlain Language Relevant InformationRelevant Information ldquoldquoThe JURYrdquoThe JURYrdquo Have your partner Have your partner
reviewreview
Medical HistoryMedical History AllergiesAllergies MedicationsMedications Chief ComplaintChief Complaint Trauma Trauma
MechanismMechanism Safety Safety
EquipmentEquipment
Vital signsVital signs Blood Blood
PressurePressure PulsePulse RespirationsRespirations Lung SoundsLung Sounds Cap refillCap refill Blood Blood
GlucoseGlucose PupilsPupils
OrganizationOrganization
S O A PS O A P CHARTCHART CHRONOLOGICAL CHRONOLOGICAL
SOAPSOAP
What happenedWhat happened What did you What did you
findfind What do you What do you
thinkthink What did you doWhat did you do
(S) (Subjective) What happened(S) (Subjective) What happened
Medic 27 responded emergent on a 39 year old female who had a syncope from the standing position Patient reports that she
was at a party when she began to feel nauseous Walked into back room and then
passed out on floor Witnesses report patient slumped forward on to a couch and then slid
backward to a carpeted floor Patient also reports that she recalls waking up on floor feeling cold and shivering Patient moved to bed with assistance A bystander called 911
for assistance
(O) (Objective) What did you find(O) (Objective) What did you find
Upon initial contact patient laying in bed in Upon initial contact patient laying in bed in bedroom Alert and oriented to name place bedroom Alert and oriented to name place
time and event Skin warm and dry with time and event Skin warm and dry with normal color and tone Mild muscle tremors normal color and tone Mild muscle tremors
(shivers) in arms and legs Patient does (shivers) in arms and legs Patient does report feeling cold Head normocephalic report feeling cold Head normocephalic without abnormality on visualization or without abnormality on visualization or
palpation Neck midline and intact without palpation Neck midline and intact without pain on palpation or movement Thoracic pain on palpation or movement Thoracic
lumbar and sacral spine intact without pain lumbar and sacral spine intact without pain on palpation or spontaneous movementon palpation or spontaneous movement
My WayMy Way
Level of ConsciousnessLevel of Consciousness Airway Breathing CirculationAirway Breathing Circulation Skin color and tempSkin color and temp Head to Toe ExamHead to Toe Exam Pertinent NegativePertinent Negative
(A) Assessment (What do you think)(A) Assessment (What do you think)
Patient transported to Hospital with seizure Patient transported to Hospital with seizure like activitylike activity
Not a diagnosisNot a diagnosis
Protocol FollowedProtocol Followed
(P) Plan What did you do(P) Plan What did you do
Patient transported non-emergent to Aurora Patient transported non-emergent to Aurora Medical Center emergency room Patient Medical Center emergency room Patient transported without change in status or transported without change in status or
level of consciousness Patients treatment level of consciousness Patients treatment plan included full secondary assessment plan included full secondary assessment detailed neurological examination vital detailed neurological examination vital
signs cardiac monitoring pulse oximetry signs cardiac monitoring pulse oximetry and supplemental oxygen Following hand and supplemental oxygen Following hand off report to staff patient left in hospital off report to staff patient left in hospital bed with rails up and staff in attendancebed with rails up and staff in attendance
C H A R TC H A R T
Chief ComplaintChief Complaint HistoryHistory AllergiesAllergies Rx-TreatmentRx-Treatment TransportTransport
(C) Chief Complaint(C) Chief Complaint
Medic 27 responded emergent on a 39 year old female who had a syncope from the standing position
(H) History Present Illness(H) History Present Illness
HPI (history of present illnessinjury) PMH (past medical history) PQRST AMPLE MOI Onset Signs and Symptoms
(A) Assessment(A) Assessment
Include both negative and positive findings Responses the patient has to your
assessment such as the presence or lack of pain andor the presence or lack of sensation
Diagnostic Testing ECG Pulse Oximetry Capnography Blood Glucose Monitoring
(R) Rx-Treatment(R) Rx-Treatment
Document your treatmentDocument your treatment Responses from the Patient to RxResponses from the Patient to Rx Changes in Patients conditionChanges in Patients condition
Example Example ldquoPain decreased to 510 from ldquoPain decreased to 510 from 710 after NTG administered710 after NTG administered
(T) Transport(T) Transport
Where did you goWhere did you go Change in condition during Change in condition during
transporttransport Alteration from ProtocolAlteration from Protocol Who did you turn care over to Who did you turn care over to
(Name if Possible) Ie RN Robinson(Name if Possible) Ie RN Robinson Patency of airway and IV fluidsPatency of airway and IV fluids
CHRONOLOGICALCHRONOLOGICAL
ldquoldquoWrite like your brain thinks itrdquoWrite like your brain thinks itrdquo
Dispatched non-emergent to University Hospitals Dispatched non-emergent to University Hospitals Emergency Educations center for a transport to Emergency Educations center for a transport to UW ER Arrived on floor and met by staff who UW ER Arrived on floor and met by staff who advised us that the patient was suffering from advised us that the patient was suffering from severe PES (Paramedic Education Syndrome) severe PES (Paramedic Education Syndrome) Patient is Mr D a 48 yo male with hx of PES and Patient is Mr D a 48 yo male with hx of PES and CHF who presented with chest pain and CHF who presented with chest pain and dyspneahellipdyspneahellip
Errors and FalsificationsErrors and Falsifications
Avoid ErrorsAvoid Errors Admit when you made a mistakeAdmit when you made a mistake
Revise if necessaryRevise if necessary Note date and time of revisionNote date and time of revision Keep original documentKeep original document Include purpose of the revisionInclude purpose of the revision Only the original author can make the Only the original author can make the
correctioncorrection
Errors and FalsificationsErrors and Falsifications
Always be honest and through in your Always be honest and through in your documentationdocumentation
CorrectionsCorrections Add a supplement on electronic reportsAdd a supplement on electronic reports One line across the error initial the One line across the error initial the
mistake and make the corrections on mistake and make the corrections on written reportswritten reports
Complete reports as soon as possible Complete reports as soon as possible Lost reports have HUGE legal implicationsLost reports have HUGE legal implications Dont keep copies of your reportsDont keep copies of your reports
HIPPAHIPPA
What Happens on What Happens on the Ambulance the Ambulance stays on the stays on the ambulance ambulance
Health Health InsuranceInsurance PortabilityPortability PrivacyPrivacy AccountabilityAccountability
HIPPAHIPPA
Protects the security and privacy of Protects the security and privacy of all medical records and other health all medical records and other health information used or shared in any information used or shared in any formform
Protects patients rights by giving Protects patients rights by giving access to health information and access to health information and control over how it is usedcontrol over how it is used
PHIPHI Protected Heath InformationProtected Heath Information
Information that relates toInformation that relates to The health of an individualThe health of an individual Health care provided to that individualHealth care provided to that individual Payment of heath care providedPayment of heath care provided
What can be sharedWhat can be shared
Health Insurance Company my need Health Insurance Company my need information to process a claiminformation to process a claim
Caregivers involved with direct care Caregivers involved with direct care Quality Assurance when necessaryQuality Assurance when necessary
Special ConsiderationsSpecial Considerations
Exposure and InjuryExposure and Injury Mass CasualtyMass Casualty Interfacility TransportsInterfacility Transports RefusalsRefusals
Mass Casualty EventsMass Casualty Events
Documentation may have to be Documentation may have to be postponedpostponed
Follow Local Policy and ProcedureFollow Local Policy and Procedure Comprehensive run report must be Comprehensive run report must be
completed for each patient when completed for each patient when time permitstime permits
Refusal of CareRefusal of Care
Potential for LiabilityPotential for Liability Good DocumentationGood Documentation Make it clearMake it clear
Refusal of CareRefusal of Care
The litigation rate for EMS has been steadily increasing
1048657 According to one study patients evaluatedby paramedics but not transported to thehospital account for 50 to 90 of EMSlawsuitsrdquo
1048657 Documentation is your best defenserdquo
DocumentationDocumentation
Physical FindingsPhysical Findings The advice you give the patient about The advice you give the patient about
being transported and the associated being transported and the associated risks for not being transportedrisks for not being transported
Clinical indications that patient is Clinical indications that patient is competent to make a rational decisioncompetent to make a rational decision
Signatures of the patient and witnessSignatures of the patient and witness Full narrativeFull narrative Advise to call 911 if condition changesAdvise to call 911 if condition changes
Do not at any time attempt to talk the patient out of going to the hospital
If you feel strongly that the patient should be seen make every attempt to convince them they should be seen
Donrsquot say lsquo I agree you donrsquot need to gordquo even if you agree
What not to sayWhat not to say
A patient suffers a diabetic emergency She is treated by the local EMS crew with an A patient suffers a diabetic emergency She is treated by the local EMS crew with an IV an ampule of D50 and transported to the closet hospital despite family members IV an ampule of D50 and transported to the closet hospital despite family members telling you that the patient does not go theretelling you that the patient does not go there
Transport is uneventful and care is turned over to the ED Nurse with a quick verbal Transport is uneventful and care is turned over to the ED Nurse with a quick verbal reportreport
An hour later a private ambulance is called to transport the patient to her desired An hour later a private ambulance is called to transport the patient to her desired hospital for definitive care They notice the IV has infiltrated and D50 got into her hospital for definitive care They notice the IV has infiltrated and D50 got into her surrounding tissuessurrounding tissues
The patient suffers significant tissue damage which requires a fasciotomy to The patient suffers significant tissue damage which requires a fasciotomy to decompress her hand and forearm She has permanent nerve damage and requires decompress her hand and forearm She has permanent nerve damage and requires skin graftingskin grafting
Initial Transport Agency-CFDInitial Transport Agency-CFD
First Receiving Hospital-St Anthony HospitalFirst Receiving Hospital-St Anthony Hospital
Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998
Lets Finish upLets Finish up
Be ProfessionalBe Professional AccurateAccurate ConsistentConsistent ThroughThrough ClearClear BriefBrief Paint the PicturePaint the Picture CollaborativeCollaborative
Legible spelling Legible spelling correctcorrect
Tell the TruthTell the Truth Donrsquot duplicate infoDonrsquot duplicate info Follow ProtocolsFollow Protocols Plain LanguagePlain Language Relevant InformationRelevant Information ldquoldquoThe JURYrdquoThe JURYrdquo Have your partner Have your partner
reviewreview
Vital signsVital signs Blood Blood
PressurePressure PulsePulse RespirationsRespirations Lung SoundsLung Sounds Cap refillCap refill Blood Blood
GlucoseGlucose PupilsPupils
OrganizationOrganization
S O A PS O A P CHARTCHART CHRONOLOGICAL CHRONOLOGICAL
SOAPSOAP
What happenedWhat happened What did you What did you
findfind What do you What do you
thinkthink What did you doWhat did you do
(S) (Subjective) What happened(S) (Subjective) What happened
Medic 27 responded emergent on a 39 year old female who had a syncope from the standing position Patient reports that she
was at a party when she began to feel nauseous Walked into back room and then
passed out on floor Witnesses report patient slumped forward on to a couch and then slid
backward to a carpeted floor Patient also reports that she recalls waking up on floor feeling cold and shivering Patient moved to bed with assistance A bystander called 911
for assistance
(O) (Objective) What did you find(O) (Objective) What did you find
Upon initial contact patient laying in bed in Upon initial contact patient laying in bed in bedroom Alert and oriented to name place bedroom Alert and oriented to name place
time and event Skin warm and dry with time and event Skin warm and dry with normal color and tone Mild muscle tremors normal color and tone Mild muscle tremors
(shivers) in arms and legs Patient does (shivers) in arms and legs Patient does report feeling cold Head normocephalic report feeling cold Head normocephalic without abnormality on visualization or without abnormality on visualization or
palpation Neck midline and intact without palpation Neck midline and intact without pain on palpation or movement Thoracic pain on palpation or movement Thoracic
lumbar and sacral spine intact without pain lumbar and sacral spine intact without pain on palpation or spontaneous movementon palpation or spontaneous movement
My WayMy Way
Level of ConsciousnessLevel of Consciousness Airway Breathing CirculationAirway Breathing Circulation Skin color and tempSkin color and temp Head to Toe ExamHead to Toe Exam Pertinent NegativePertinent Negative
(A) Assessment (What do you think)(A) Assessment (What do you think)
Patient transported to Hospital with seizure Patient transported to Hospital with seizure like activitylike activity
Not a diagnosisNot a diagnosis
Protocol FollowedProtocol Followed
(P) Plan What did you do(P) Plan What did you do
Patient transported non-emergent to Aurora Patient transported non-emergent to Aurora Medical Center emergency room Patient Medical Center emergency room Patient transported without change in status or transported without change in status or
level of consciousness Patients treatment level of consciousness Patients treatment plan included full secondary assessment plan included full secondary assessment detailed neurological examination vital detailed neurological examination vital
signs cardiac monitoring pulse oximetry signs cardiac monitoring pulse oximetry and supplemental oxygen Following hand and supplemental oxygen Following hand off report to staff patient left in hospital off report to staff patient left in hospital bed with rails up and staff in attendancebed with rails up and staff in attendance
C H A R TC H A R T
Chief ComplaintChief Complaint HistoryHistory AllergiesAllergies Rx-TreatmentRx-Treatment TransportTransport
(C) Chief Complaint(C) Chief Complaint
Medic 27 responded emergent on a 39 year old female who had a syncope from the standing position
(H) History Present Illness(H) History Present Illness
HPI (history of present illnessinjury) PMH (past medical history) PQRST AMPLE MOI Onset Signs and Symptoms
(A) Assessment(A) Assessment
Include both negative and positive findings Responses the patient has to your
assessment such as the presence or lack of pain andor the presence or lack of sensation
Diagnostic Testing ECG Pulse Oximetry Capnography Blood Glucose Monitoring
(R) Rx-Treatment(R) Rx-Treatment
Document your treatmentDocument your treatment Responses from the Patient to RxResponses from the Patient to Rx Changes in Patients conditionChanges in Patients condition
Example Example ldquoPain decreased to 510 from ldquoPain decreased to 510 from 710 after NTG administered710 after NTG administered
(T) Transport(T) Transport
Where did you goWhere did you go Change in condition during Change in condition during
transporttransport Alteration from ProtocolAlteration from Protocol Who did you turn care over to Who did you turn care over to
(Name if Possible) Ie RN Robinson(Name if Possible) Ie RN Robinson Patency of airway and IV fluidsPatency of airway and IV fluids
CHRONOLOGICALCHRONOLOGICAL
ldquoldquoWrite like your brain thinks itrdquoWrite like your brain thinks itrdquo
Dispatched non-emergent to University Hospitals Dispatched non-emergent to University Hospitals Emergency Educations center for a transport to Emergency Educations center for a transport to UW ER Arrived on floor and met by staff who UW ER Arrived on floor and met by staff who advised us that the patient was suffering from advised us that the patient was suffering from severe PES (Paramedic Education Syndrome) severe PES (Paramedic Education Syndrome) Patient is Mr D a 48 yo male with hx of PES and Patient is Mr D a 48 yo male with hx of PES and CHF who presented with chest pain and CHF who presented with chest pain and dyspneahellipdyspneahellip
Errors and FalsificationsErrors and Falsifications
Avoid ErrorsAvoid Errors Admit when you made a mistakeAdmit when you made a mistake
Revise if necessaryRevise if necessary Note date and time of revisionNote date and time of revision Keep original documentKeep original document Include purpose of the revisionInclude purpose of the revision Only the original author can make the Only the original author can make the
correctioncorrection
Errors and FalsificationsErrors and Falsifications
Always be honest and through in your Always be honest and through in your documentationdocumentation
CorrectionsCorrections Add a supplement on electronic reportsAdd a supplement on electronic reports One line across the error initial the One line across the error initial the
mistake and make the corrections on mistake and make the corrections on written reportswritten reports
Complete reports as soon as possible Complete reports as soon as possible Lost reports have HUGE legal implicationsLost reports have HUGE legal implications Dont keep copies of your reportsDont keep copies of your reports
HIPPAHIPPA
What Happens on What Happens on the Ambulance the Ambulance stays on the stays on the ambulance ambulance
Health Health InsuranceInsurance PortabilityPortability PrivacyPrivacy AccountabilityAccountability
HIPPAHIPPA
Protects the security and privacy of Protects the security and privacy of all medical records and other health all medical records and other health information used or shared in any information used or shared in any formform
Protects patients rights by giving Protects patients rights by giving access to health information and access to health information and control over how it is usedcontrol over how it is used
PHIPHI Protected Heath InformationProtected Heath Information
Information that relates toInformation that relates to The health of an individualThe health of an individual Health care provided to that individualHealth care provided to that individual Payment of heath care providedPayment of heath care provided
What can be sharedWhat can be shared
Health Insurance Company my need Health Insurance Company my need information to process a claiminformation to process a claim
Caregivers involved with direct care Caregivers involved with direct care Quality Assurance when necessaryQuality Assurance when necessary
Special ConsiderationsSpecial Considerations
Exposure and InjuryExposure and Injury Mass CasualtyMass Casualty Interfacility TransportsInterfacility Transports RefusalsRefusals
Mass Casualty EventsMass Casualty Events
Documentation may have to be Documentation may have to be postponedpostponed
Follow Local Policy and ProcedureFollow Local Policy and Procedure Comprehensive run report must be Comprehensive run report must be
completed for each patient when completed for each patient when time permitstime permits
Refusal of CareRefusal of Care
Potential for LiabilityPotential for Liability Good DocumentationGood Documentation Make it clearMake it clear
Refusal of CareRefusal of Care
The litigation rate for EMS has been steadily increasing
1048657 According to one study patients evaluatedby paramedics but not transported to thehospital account for 50 to 90 of EMSlawsuitsrdquo
1048657 Documentation is your best defenserdquo
DocumentationDocumentation
Physical FindingsPhysical Findings The advice you give the patient about The advice you give the patient about
being transported and the associated being transported and the associated risks for not being transportedrisks for not being transported
Clinical indications that patient is Clinical indications that patient is competent to make a rational decisioncompetent to make a rational decision
Signatures of the patient and witnessSignatures of the patient and witness Full narrativeFull narrative Advise to call 911 if condition changesAdvise to call 911 if condition changes
Do not at any time attempt to talk the patient out of going to the hospital
If you feel strongly that the patient should be seen make every attempt to convince them they should be seen
Donrsquot say lsquo I agree you donrsquot need to gordquo even if you agree
What not to sayWhat not to say
A patient suffers a diabetic emergency She is treated by the local EMS crew with an A patient suffers a diabetic emergency She is treated by the local EMS crew with an IV an ampule of D50 and transported to the closet hospital despite family members IV an ampule of D50 and transported to the closet hospital despite family members telling you that the patient does not go theretelling you that the patient does not go there
Transport is uneventful and care is turned over to the ED Nurse with a quick verbal Transport is uneventful and care is turned over to the ED Nurse with a quick verbal reportreport
An hour later a private ambulance is called to transport the patient to her desired An hour later a private ambulance is called to transport the patient to her desired hospital for definitive care They notice the IV has infiltrated and D50 got into her hospital for definitive care They notice the IV has infiltrated and D50 got into her surrounding tissuessurrounding tissues
The patient suffers significant tissue damage which requires a fasciotomy to The patient suffers significant tissue damage which requires a fasciotomy to decompress her hand and forearm She has permanent nerve damage and requires decompress her hand and forearm She has permanent nerve damage and requires skin graftingskin grafting
Initial Transport Agency-CFDInitial Transport Agency-CFD
First Receiving Hospital-St Anthony HospitalFirst Receiving Hospital-St Anthony Hospital
Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998
Lets Finish upLets Finish up
Be ProfessionalBe Professional AccurateAccurate ConsistentConsistent ThroughThrough ClearClear BriefBrief Paint the PicturePaint the Picture CollaborativeCollaborative
Legible spelling Legible spelling correctcorrect
Tell the TruthTell the Truth Donrsquot duplicate infoDonrsquot duplicate info Follow ProtocolsFollow Protocols Plain LanguagePlain Language Relevant InformationRelevant Information ldquoldquoThe JURYrdquoThe JURYrdquo Have your partner Have your partner
reviewreview
OrganizationOrganization
S O A PS O A P CHARTCHART CHRONOLOGICAL CHRONOLOGICAL
SOAPSOAP
What happenedWhat happened What did you What did you
findfind What do you What do you
thinkthink What did you doWhat did you do
(S) (Subjective) What happened(S) (Subjective) What happened
Medic 27 responded emergent on a 39 year old female who had a syncope from the standing position Patient reports that she
was at a party when she began to feel nauseous Walked into back room and then
passed out on floor Witnesses report patient slumped forward on to a couch and then slid
backward to a carpeted floor Patient also reports that she recalls waking up on floor feeling cold and shivering Patient moved to bed with assistance A bystander called 911
for assistance
(O) (Objective) What did you find(O) (Objective) What did you find
Upon initial contact patient laying in bed in Upon initial contact patient laying in bed in bedroom Alert and oriented to name place bedroom Alert and oriented to name place
time and event Skin warm and dry with time and event Skin warm and dry with normal color and tone Mild muscle tremors normal color and tone Mild muscle tremors
(shivers) in arms and legs Patient does (shivers) in arms and legs Patient does report feeling cold Head normocephalic report feeling cold Head normocephalic without abnormality on visualization or without abnormality on visualization or
palpation Neck midline and intact without palpation Neck midline and intact without pain on palpation or movement Thoracic pain on palpation or movement Thoracic
lumbar and sacral spine intact without pain lumbar and sacral spine intact without pain on palpation or spontaneous movementon palpation or spontaneous movement
My WayMy Way
Level of ConsciousnessLevel of Consciousness Airway Breathing CirculationAirway Breathing Circulation Skin color and tempSkin color and temp Head to Toe ExamHead to Toe Exam Pertinent NegativePertinent Negative
(A) Assessment (What do you think)(A) Assessment (What do you think)
Patient transported to Hospital with seizure Patient transported to Hospital with seizure like activitylike activity
Not a diagnosisNot a diagnosis
Protocol FollowedProtocol Followed
(P) Plan What did you do(P) Plan What did you do
Patient transported non-emergent to Aurora Patient transported non-emergent to Aurora Medical Center emergency room Patient Medical Center emergency room Patient transported without change in status or transported without change in status or
level of consciousness Patients treatment level of consciousness Patients treatment plan included full secondary assessment plan included full secondary assessment detailed neurological examination vital detailed neurological examination vital
signs cardiac monitoring pulse oximetry signs cardiac monitoring pulse oximetry and supplemental oxygen Following hand and supplemental oxygen Following hand off report to staff patient left in hospital off report to staff patient left in hospital bed with rails up and staff in attendancebed with rails up and staff in attendance
C H A R TC H A R T
Chief ComplaintChief Complaint HistoryHistory AllergiesAllergies Rx-TreatmentRx-Treatment TransportTransport
(C) Chief Complaint(C) Chief Complaint
Medic 27 responded emergent on a 39 year old female who had a syncope from the standing position
(H) History Present Illness(H) History Present Illness
HPI (history of present illnessinjury) PMH (past medical history) PQRST AMPLE MOI Onset Signs and Symptoms
(A) Assessment(A) Assessment
Include both negative and positive findings Responses the patient has to your
assessment such as the presence or lack of pain andor the presence or lack of sensation
Diagnostic Testing ECG Pulse Oximetry Capnography Blood Glucose Monitoring
(R) Rx-Treatment(R) Rx-Treatment
Document your treatmentDocument your treatment Responses from the Patient to RxResponses from the Patient to Rx Changes in Patients conditionChanges in Patients condition
Example Example ldquoPain decreased to 510 from ldquoPain decreased to 510 from 710 after NTG administered710 after NTG administered
(T) Transport(T) Transport
Where did you goWhere did you go Change in condition during Change in condition during
transporttransport Alteration from ProtocolAlteration from Protocol Who did you turn care over to Who did you turn care over to
(Name if Possible) Ie RN Robinson(Name if Possible) Ie RN Robinson Patency of airway and IV fluidsPatency of airway and IV fluids
CHRONOLOGICALCHRONOLOGICAL
ldquoldquoWrite like your brain thinks itrdquoWrite like your brain thinks itrdquo
Dispatched non-emergent to University Hospitals Dispatched non-emergent to University Hospitals Emergency Educations center for a transport to Emergency Educations center for a transport to UW ER Arrived on floor and met by staff who UW ER Arrived on floor and met by staff who advised us that the patient was suffering from advised us that the patient was suffering from severe PES (Paramedic Education Syndrome) severe PES (Paramedic Education Syndrome) Patient is Mr D a 48 yo male with hx of PES and Patient is Mr D a 48 yo male with hx of PES and CHF who presented with chest pain and CHF who presented with chest pain and dyspneahellipdyspneahellip
Errors and FalsificationsErrors and Falsifications
Avoid ErrorsAvoid Errors Admit when you made a mistakeAdmit when you made a mistake
Revise if necessaryRevise if necessary Note date and time of revisionNote date and time of revision Keep original documentKeep original document Include purpose of the revisionInclude purpose of the revision Only the original author can make the Only the original author can make the
correctioncorrection
Errors and FalsificationsErrors and Falsifications
Always be honest and through in your Always be honest and through in your documentationdocumentation
CorrectionsCorrections Add a supplement on electronic reportsAdd a supplement on electronic reports One line across the error initial the One line across the error initial the
mistake and make the corrections on mistake and make the corrections on written reportswritten reports
Complete reports as soon as possible Complete reports as soon as possible Lost reports have HUGE legal implicationsLost reports have HUGE legal implications Dont keep copies of your reportsDont keep copies of your reports
HIPPAHIPPA
What Happens on What Happens on the Ambulance the Ambulance stays on the stays on the ambulance ambulance
Health Health InsuranceInsurance PortabilityPortability PrivacyPrivacy AccountabilityAccountability
HIPPAHIPPA
Protects the security and privacy of Protects the security and privacy of all medical records and other health all medical records and other health information used or shared in any information used or shared in any formform
Protects patients rights by giving Protects patients rights by giving access to health information and access to health information and control over how it is usedcontrol over how it is used
PHIPHI Protected Heath InformationProtected Heath Information
Information that relates toInformation that relates to The health of an individualThe health of an individual Health care provided to that individualHealth care provided to that individual Payment of heath care providedPayment of heath care provided
What can be sharedWhat can be shared
Health Insurance Company my need Health Insurance Company my need information to process a claiminformation to process a claim
Caregivers involved with direct care Caregivers involved with direct care Quality Assurance when necessaryQuality Assurance when necessary
Special ConsiderationsSpecial Considerations
Exposure and InjuryExposure and Injury Mass CasualtyMass Casualty Interfacility TransportsInterfacility Transports RefusalsRefusals
Mass Casualty EventsMass Casualty Events
Documentation may have to be Documentation may have to be postponedpostponed
Follow Local Policy and ProcedureFollow Local Policy and Procedure Comprehensive run report must be Comprehensive run report must be
completed for each patient when completed for each patient when time permitstime permits
Refusal of CareRefusal of Care
Potential for LiabilityPotential for Liability Good DocumentationGood Documentation Make it clearMake it clear
Refusal of CareRefusal of Care
The litigation rate for EMS has been steadily increasing
1048657 According to one study patients evaluatedby paramedics but not transported to thehospital account for 50 to 90 of EMSlawsuitsrdquo
1048657 Documentation is your best defenserdquo
DocumentationDocumentation
Physical FindingsPhysical Findings The advice you give the patient about The advice you give the patient about
being transported and the associated being transported and the associated risks for not being transportedrisks for not being transported
Clinical indications that patient is Clinical indications that patient is competent to make a rational decisioncompetent to make a rational decision
Signatures of the patient and witnessSignatures of the patient and witness Full narrativeFull narrative Advise to call 911 if condition changesAdvise to call 911 if condition changes
Do not at any time attempt to talk the patient out of going to the hospital
If you feel strongly that the patient should be seen make every attempt to convince them they should be seen
Donrsquot say lsquo I agree you donrsquot need to gordquo even if you agree
What not to sayWhat not to say
A patient suffers a diabetic emergency She is treated by the local EMS crew with an A patient suffers a diabetic emergency She is treated by the local EMS crew with an IV an ampule of D50 and transported to the closet hospital despite family members IV an ampule of D50 and transported to the closet hospital despite family members telling you that the patient does not go theretelling you that the patient does not go there
Transport is uneventful and care is turned over to the ED Nurse with a quick verbal Transport is uneventful and care is turned over to the ED Nurse with a quick verbal reportreport
An hour later a private ambulance is called to transport the patient to her desired An hour later a private ambulance is called to transport the patient to her desired hospital for definitive care They notice the IV has infiltrated and D50 got into her hospital for definitive care They notice the IV has infiltrated and D50 got into her surrounding tissuessurrounding tissues
The patient suffers significant tissue damage which requires a fasciotomy to The patient suffers significant tissue damage which requires a fasciotomy to decompress her hand and forearm She has permanent nerve damage and requires decompress her hand and forearm She has permanent nerve damage and requires skin graftingskin grafting
Initial Transport Agency-CFDInitial Transport Agency-CFD
First Receiving Hospital-St Anthony HospitalFirst Receiving Hospital-St Anthony Hospital
Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998
Lets Finish upLets Finish up
Be ProfessionalBe Professional AccurateAccurate ConsistentConsistent ThroughThrough ClearClear BriefBrief Paint the PicturePaint the Picture CollaborativeCollaborative
Legible spelling Legible spelling correctcorrect
Tell the TruthTell the Truth Donrsquot duplicate infoDonrsquot duplicate info Follow ProtocolsFollow Protocols Plain LanguagePlain Language Relevant InformationRelevant Information ldquoldquoThe JURYrdquoThe JURYrdquo Have your partner Have your partner
reviewreview
SOAPSOAP
What happenedWhat happened What did you What did you
findfind What do you What do you
thinkthink What did you doWhat did you do
(S) (Subjective) What happened(S) (Subjective) What happened
Medic 27 responded emergent on a 39 year old female who had a syncope from the standing position Patient reports that she
was at a party when she began to feel nauseous Walked into back room and then
passed out on floor Witnesses report patient slumped forward on to a couch and then slid
backward to a carpeted floor Patient also reports that she recalls waking up on floor feeling cold and shivering Patient moved to bed with assistance A bystander called 911
for assistance
(O) (Objective) What did you find(O) (Objective) What did you find
Upon initial contact patient laying in bed in Upon initial contact patient laying in bed in bedroom Alert and oriented to name place bedroom Alert and oriented to name place
time and event Skin warm and dry with time and event Skin warm and dry with normal color and tone Mild muscle tremors normal color and tone Mild muscle tremors
(shivers) in arms and legs Patient does (shivers) in arms and legs Patient does report feeling cold Head normocephalic report feeling cold Head normocephalic without abnormality on visualization or without abnormality on visualization or
palpation Neck midline and intact without palpation Neck midline and intact without pain on palpation or movement Thoracic pain on palpation or movement Thoracic
lumbar and sacral spine intact without pain lumbar and sacral spine intact without pain on palpation or spontaneous movementon palpation or spontaneous movement
My WayMy Way
Level of ConsciousnessLevel of Consciousness Airway Breathing CirculationAirway Breathing Circulation Skin color and tempSkin color and temp Head to Toe ExamHead to Toe Exam Pertinent NegativePertinent Negative
(A) Assessment (What do you think)(A) Assessment (What do you think)
Patient transported to Hospital with seizure Patient transported to Hospital with seizure like activitylike activity
Not a diagnosisNot a diagnosis
Protocol FollowedProtocol Followed
(P) Plan What did you do(P) Plan What did you do
Patient transported non-emergent to Aurora Patient transported non-emergent to Aurora Medical Center emergency room Patient Medical Center emergency room Patient transported without change in status or transported without change in status or
level of consciousness Patients treatment level of consciousness Patients treatment plan included full secondary assessment plan included full secondary assessment detailed neurological examination vital detailed neurological examination vital
signs cardiac monitoring pulse oximetry signs cardiac monitoring pulse oximetry and supplemental oxygen Following hand and supplemental oxygen Following hand off report to staff patient left in hospital off report to staff patient left in hospital bed with rails up and staff in attendancebed with rails up and staff in attendance
C H A R TC H A R T
Chief ComplaintChief Complaint HistoryHistory AllergiesAllergies Rx-TreatmentRx-Treatment TransportTransport
(C) Chief Complaint(C) Chief Complaint
Medic 27 responded emergent on a 39 year old female who had a syncope from the standing position
(H) History Present Illness(H) History Present Illness
HPI (history of present illnessinjury) PMH (past medical history) PQRST AMPLE MOI Onset Signs and Symptoms
(A) Assessment(A) Assessment
Include both negative and positive findings Responses the patient has to your
assessment such as the presence or lack of pain andor the presence or lack of sensation
Diagnostic Testing ECG Pulse Oximetry Capnography Blood Glucose Monitoring
(R) Rx-Treatment(R) Rx-Treatment
Document your treatmentDocument your treatment Responses from the Patient to RxResponses from the Patient to Rx Changes in Patients conditionChanges in Patients condition
Example Example ldquoPain decreased to 510 from ldquoPain decreased to 510 from 710 after NTG administered710 after NTG administered
(T) Transport(T) Transport
Where did you goWhere did you go Change in condition during Change in condition during
transporttransport Alteration from ProtocolAlteration from Protocol Who did you turn care over to Who did you turn care over to
(Name if Possible) Ie RN Robinson(Name if Possible) Ie RN Robinson Patency of airway and IV fluidsPatency of airway and IV fluids
CHRONOLOGICALCHRONOLOGICAL
ldquoldquoWrite like your brain thinks itrdquoWrite like your brain thinks itrdquo
Dispatched non-emergent to University Hospitals Dispatched non-emergent to University Hospitals Emergency Educations center for a transport to Emergency Educations center for a transport to UW ER Arrived on floor and met by staff who UW ER Arrived on floor and met by staff who advised us that the patient was suffering from advised us that the patient was suffering from severe PES (Paramedic Education Syndrome) severe PES (Paramedic Education Syndrome) Patient is Mr D a 48 yo male with hx of PES and Patient is Mr D a 48 yo male with hx of PES and CHF who presented with chest pain and CHF who presented with chest pain and dyspneahellipdyspneahellip
Errors and FalsificationsErrors and Falsifications
Avoid ErrorsAvoid Errors Admit when you made a mistakeAdmit when you made a mistake
Revise if necessaryRevise if necessary Note date and time of revisionNote date and time of revision Keep original documentKeep original document Include purpose of the revisionInclude purpose of the revision Only the original author can make the Only the original author can make the
correctioncorrection
Errors and FalsificationsErrors and Falsifications
Always be honest and through in your Always be honest and through in your documentationdocumentation
CorrectionsCorrections Add a supplement on electronic reportsAdd a supplement on electronic reports One line across the error initial the One line across the error initial the
mistake and make the corrections on mistake and make the corrections on written reportswritten reports
Complete reports as soon as possible Complete reports as soon as possible Lost reports have HUGE legal implicationsLost reports have HUGE legal implications Dont keep copies of your reportsDont keep copies of your reports
HIPPAHIPPA
What Happens on What Happens on the Ambulance the Ambulance stays on the stays on the ambulance ambulance
Health Health InsuranceInsurance PortabilityPortability PrivacyPrivacy AccountabilityAccountability
HIPPAHIPPA
Protects the security and privacy of Protects the security and privacy of all medical records and other health all medical records and other health information used or shared in any information used or shared in any formform
Protects patients rights by giving Protects patients rights by giving access to health information and access to health information and control over how it is usedcontrol over how it is used
PHIPHI Protected Heath InformationProtected Heath Information
Information that relates toInformation that relates to The health of an individualThe health of an individual Health care provided to that individualHealth care provided to that individual Payment of heath care providedPayment of heath care provided
What can be sharedWhat can be shared
Health Insurance Company my need Health Insurance Company my need information to process a claiminformation to process a claim
Caregivers involved with direct care Caregivers involved with direct care Quality Assurance when necessaryQuality Assurance when necessary
Special ConsiderationsSpecial Considerations
Exposure and InjuryExposure and Injury Mass CasualtyMass Casualty Interfacility TransportsInterfacility Transports RefusalsRefusals
Mass Casualty EventsMass Casualty Events
Documentation may have to be Documentation may have to be postponedpostponed
Follow Local Policy and ProcedureFollow Local Policy and Procedure Comprehensive run report must be Comprehensive run report must be
completed for each patient when completed for each patient when time permitstime permits
Refusal of CareRefusal of Care
Potential for LiabilityPotential for Liability Good DocumentationGood Documentation Make it clearMake it clear
Refusal of CareRefusal of Care
The litigation rate for EMS has been steadily increasing
1048657 According to one study patients evaluatedby paramedics but not transported to thehospital account for 50 to 90 of EMSlawsuitsrdquo
1048657 Documentation is your best defenserdquo
DocumentationDocumentation
Physical FindingsPhysical Findings The advice you give the patient about The advice you give the patient about
being transported and the associated being transported and the associated risks for not being transportedrisks for not being transported
Clinical indications that patient is Clinical indications that patient is competent to make a rational decisioncompetent to make a rational decision
Signatures of the patient and witnessSignatures of the patient and witness Full narrativeFull narrative Advise to call 911 if condition changesAdvise to call 911 if condition changes
Do not at any time attempt to talk the patient out of going to the hospital
If you feel strongly that the patient should be seen make every attempt to convince them they should be seen
Donrsquot say lsquo I agree you donrsquot need to gordquo even if you agree
What not to sayWhat not to say
A patient suffers a diabetic emergency She is treated by the local EMS crew with an A patient suffers a diabetic emergency She is treated by the local EMS crew with an IV an ampule of D50 and transported to the closet hospital despite family members IV an ampule of D50 and transported to the closet hospital despite family members telling you that the patient does not go theretelling you that the patient does not go there
Transport is uneventful and care is turned over to the ED Nurse with a quick verbal Transport is uneventful and care is turned over to the ED Nurse with a quick verbal reportreport
An hour later a private ambulance is called to transport the patient to her desired An hour later a private ambulance is called to transport the patient to her desired hospital for definitive care They notice the IV has infiltrated and D50 got into her hospital for definitive care They notice the IV has infiltrated and D50 got into her surrounding tissuessurrounding tissues
The patient suffers significant tissue damage which requires a fasciotomy to The patient suffers significant tissue damage which requires a fasciotomy to decompress her hand and forearm She has permanent nerve damage and requires decompress her hand and forearm She has permanent nerve damage and requires skin graftingskin grafting
Initial Transport Agency-CFDInitial Transport Agency-CFD
First Receiving Hospital-St Anthony HospitalFirst Receiving Hospital-St Anthony Hospital
Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998
Lets Finish upLets Finish up
Be ProfessionalBe Professional AccurateAccurate ConsistentConsistent ThroughThrough ClearClear BriefBrief Paint the PicturePaint the Picture CollaborativeCollaborative
Legible spelling Legible spelling correctcorrect
Tell the TruthTell the Truth Donrsquot duplicate infoDonrsquot duplicate info Follow ProtocolsFollow Protocols Plain LanguagePlain Language Relevant InformationRelevant Information ldquoldquoThe JURYrdquoThe JURYrdquo Have your partner Have your partner
reviewreview
(S) (Subjective) What happened(S) (Subjective) What happened
Medic 27 responded emergent on a 39 year old female who had a syncope from the standing position Patient reports that she
was at a party when she began to feel nauseous Walked into back room and then
passed out on floor Witnesses report patient slumped forward on to a couch and then slid
backward to a carpeted floor Patient also reports that she recalls waking up on floor feeling cold and shivering Patient moved to bed with assistance A bystander called 911
for assistance
(O) (Objective) What did you find(O) (Objective) What did you find
Upon initial contact patient laying in bed in Upon initial contact patient laying in bed in bedroom Alert and oriented to name place bedroom Alert and oriented to name place
time and event Skin warm and dry with time and event Skin warm and dry with normal color and tone Mild muscle tremors normal color and tone Mild muscle tremors
(shivers) in arms and legs Patient does (shivers) in arms and legs Patient does report feeling cold Head normocephalic report feeling cold Head normocephalic without abnormality on visualization or without abnormality on visualization or
palpation Neck midline and intact without palpation Neck midline and intact without pain on palpation or movement Thoracic pain on palpation or movement Thoracic
lumbar and sacral spine intact without pain lumbar and sacral spine intact without pain on palpation or spontaneous movementon palpation or spontaneous movement
My WayMy Way
Level of ConsciousnessLevel of Consciousness Airway Breathing CirculationAirway Breathing Circulation Skin color and tempSkin color and temp Head to Toe ExamHead to Toe Exam Pertinent NegativePertinent Negative
(A) Assessment (What do you think)(A) Assessment (What do you think)
Patient transported to Hospital with seizure Patient transported to Hospital with seizure like activitylike activity
Not a diagnosisNot a diagnosis
Protocol FollowedProtocol Followed
(P) Plan What did you do(P) Plan What did you do
Patient transported non-emergent to Aurora Patient transported non-emergent to Aurora Medical Center emergency room Patient Medical Center emergency room Patient transported without change in status or transported without change in status or
level of consciousness Patients treatment level of consciousness Patients treatment plan included full secondary assessment plan included full secondary assessment detailed neurological examination vital detailed neurological examination vital
signs cardiac monitoring pulse oximetry signs cardiac monitoring pulse oximetry and supplemental oxygen Following hand and supplemental oxygen Following hand off report to staff patient left in hospital off report to staff patient left in hospital bed with rails up and staff in attendancebed with rails up and staff in attendance
C H A R TC H A R T
Chief ComplaintChief Complaint HistoryHistory AllergiesAllergies Rx-TreatmentRx-Treatment TransportTransport
(C) Chief Complaint(C) Chief Complaint
Medic 27 responded emergent on a 39 year old female who had a syncope from the standing position
(H) History Present Illness(H) History Present Illness
HPI (history of present illnessinjury) PMH (past medical history) PQRST AMPLE MOI Onset Signs and Symptoms
(A) Assessment(A) Assessment
Include both negative and positive findings Responses the patient has to your
assessment such as the presence or lack of pain andor the presence or lack of sensation
Diagnostic Testing ECG Pulse Oximetry Capnography Blood Glucose Monitoring
(R) Rx-Treatment(R) Rx-Treatment
Document your treatmentDocument your treatment Responses from the Patient to RxResponses from the Patient to Rx Changes in Patients conditionChanges in Patients condition
Example Example ldquoPain decreased to 510 from ldquoPain decreased to 510 from 710 after NTG administered710 after NTG administered
(T) Transport(T) Transport
Where did you goWhere did you go Change in condition during Change in condition during
transporttransport Alteration from ProtocolAlteration from Protocol Who did you turn care over to Who did you turn care over to
(Name if Possible) Ie RN Robinson(Name if Possible) Ie RN Robinson Patency of airway and IV fluidsPatency of airway and IV fluids
CHRONOLOGICALCHRONOLOGICAL
ldquoldquoWrite like your brain thinks itrdquoWrite like your brain thinks itrdquo
Dispatched non-emergent to University Hospitals Dispatched non-emergent to University Hospitals Emergency Educations center for a transport to Emergency Educations center for a transport to UW ER Arrived on floor and met by staff who UW ER Arrived on floor and met by staff who advised us that the patient was suffering from advised us that the patient was suffering from severe PES (Paramedic Education Syndrome) severe PES (Paramedic Education Syndrome) Patient is Mr D a 48 yo male with hx of PES and Patient is Mr D a 48 yo male with hx of PES and CHF who presented with chest pain and CHF who presented with chest pain and dyspneahellipdyspneahellip
Errors and FalsificationsErrors and Falsifications
Avoid ErrorsAvoid Errors Admit when you made a mistakeAdmit when you made a mistake
Revise if necessaryRevise if necessary Note date and time of revisionNote date and time of revision Keep original documentKeep original document Include purpose of the revisionInclude purpose of the revision Only the original author can make the Only the original author can make the
correctioncorrection
Errors and FalsificationsErrors and Falsifications
Always be honest and through in your Always be honest and through in your documentationdocumentation
CorrectionsCorrections Add a supplement on electronic reportsAdd a supplement on electronic reports One line across the error initial the One line across the error initial the
mistake and make the corrections on mistake and make the corrections on written reportswritten reports
Complete reports as soon as possible Complete reports as soon as possible Lost reports have HUGE legal implicationsLost reports have HUGE legal implications Dont keep copies of your reportsDont keep copies of your reports
HIPPAHIPPA
What Happens on What Happens on the Ambulance the Ambulance stays on the stays on the ambulance ambulance
Health Health InsuranceInsurance PortabilityPortability PrivacyPrivacy AccountabilityAccountability
HIPPAHIPPA
Protects the security and privacy of Protects the security and privacy of all medical records and other health all medical records and other health information used or shared in any information used or shared in any formform
Protects patients rights by giving Protects patients rights by giving access to health information and access to health information and control over how it is usedcontrol over how it is used
PHIPHI Protected Heath InformationProtected Heath Information
Information that relates toInformation that relates to The health of an individualThe health of an individual Health care provided to that individualHealth care provided to that individual Payment of heath care providedPayment of heath care provided
What can be sharedWhat can be shared
Health Insurance Company my need Health Insurance Company my need information to process a claiminformation to process a claim
Caregivers involved with direct care Caregivers involved with direct care Quality Assurance when necessaryQuality Assurance when necessary
Special ConsiderationsSpecial Considerations
Exposure and InjuryExposure and Injury Mass CasualtyMass Casualty Interfacility TransportsInterfacility Transports RefusalsRefusals
Mass Casualty EventsMass Casualty Events
Documentation may have to be Documentation may have to be postponedpostponed
Follow Local Policy and ProcedureFollow Local Policy and Procedure Comprehensive run report must be Comprehensive run report must be
completed for each patient when completed for each patient when time permitstime permits
Refusal of CareRefusal of Care
Potential for LiabilityPotential for Liability Good DocumentationGood Documentation Make it clearMake it clear
Refusal of CareRefusal of Care
The litigation rate for EMS has been steadily increasing
1048657 According to one study patients evaluatedby paramedics but not transported to thehospital account for 50 to 90 of EMSlawsuitsrdquo
1048657 Documentation is your best defenserdquo
DocumentationDocumentation
Physical FindingsPhysical Findings The advice you give the patient about The advice you give the patient about
being transported and the associated being transported and the associated risks for not being transportedrisks for not being transported
Clinical indications that patient is Clinical indications that patient is competent to make a rational decisioncompetent to make a rational decision
Signatures of the patient and witnessSignatures of the patient and witness Full narrativeFull narrative Advise to call 911 if condition changesAdvise to call 911 if condition changes
Do not at any time attempt to talk the patient out of going to the hospital
If you feel strongly that the patient should be seen make every attempt to convince them they should be seen
Donrsquot say lsquo I agree you donrsquot need to gordquo even if you agree
What not to sayWhat not to say
A patient suffers a diabetic emergency She is treated by the local EMS crew with an A patient suffers a diabetic emergency She is treated by the local EMS crew with an IV an ampule of D50 and transported to the closet hospital despite family members IV an ampule of D50 and transported to the closet hospital despite family members telling you that the patient does not go theretelling you that the patient does not go there
Transport is uneventful and care is turned over to the ED Nurse with a quick verbal Transport is uneventful and care is turned over to the ED Nurse with a quick verbal reportreport
An hour later a private ambulance is called to transport the patient to her desired An hour later a private ambulance is called to transport the patient to her desired hospital for definitive care They notice the IV has infiltrated and D50 got into her hospital for definitive care They notice the IV has infiltrated and D50 got into her surrounding tissuessurrounding tissues
The patient suffers significant tissue damage which requires a fasciotomy to The patient suffers significant tissue damage which requires a fasciotomy to decompress her hand and forearm She has permanent nerve damage and requires decompress her hand and forearm She has permanent nerve damage and requires skin graftingskin grafting
Initial Transport Agency-CFDInitial Transport Agency-CFD
First Receiving Hospital-St Anthony HospitalFirst Receiving Hospital-St Anthony Hospital
Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998
Lets Finish upLets Finish up
Be ProfessionalBe Professional AccurateAccurate ConsistentConsistent ThroughThrough ClearClear BriefBrief Paint the PicturePaint the Picture CollaborativeCollaborative
Legible spelling Legible spelling correctcorrect
Tell the TruthTell the Truth Donrsquot duplicate infoDonrsquot duplicate info Follow ProtocolsFollow Protocols Plain LanguagePlain Language Relevant InformationRelevant Information ldquoldquoThe JURYrdquoThe JURYrdquo Have your partner Have your partner
reviewreview
(O) (Objective) What did you find(O) (Objective) What did you find
Upon initial contact patient laying in bed in Upon initial contact patient laying in bed in bedroom Alert and oriented to name place bedroom Alert and oriented to name place
time and event Skin warm and dry with time and event Skin warm and dry with normal color and tone Mild muscle tremors normal color and tone Mild muscle tremors
(shivers) in arms and legs Patient does (shivers) in arms and legs Patient does report feeling cold Head normocephalic report feeling cold Head normocephalic without abnormality on visualization or without abnormality on visualization or
palpation Neck midline and intact without palpation Neck midline and intact without pain on palpation or movement Thoracic pain on palpation or movement Thoracic
lumbar and sacral spine intact without pain lumbar and sacral spine intact without pain on palpation or spontaneous movementon palpation or spontaneous movement
My WayMy Way
Level of ConsciousnessLevel of Consciousness Airway Breathing CirculationAirway Breathing Circulation Skin color and tempSkin color and temp Head to Toe ExamHead to Toe Exam Pertinent NegativePertinent Negative
(A) Assessment (What do you think)(A) Assessment (What do you think)
Patient transported to Hospital with seizure Patient transported to Hospital with seizure like activitylike activity
Not a diagnosisNot a diagnosis
Protocol FollowedProtocol Followed
(P) Plan What did you do(P) Plan What did you do
Patient transported non-emergent to Aurora Patient transported non-emergent to Aurora Medical Center emergency room Patient Medical Center emergency room Patient transported without change in status or transported without change in status or
level of consciousness Patients treatment level of consciousness Patients treatment plan included full secondary assessment plan included full secondary assessment detailed neurological examination vital detailed neurological examination vital
signs cardiac monitoring pulse oximetry signs cardiac monitoring pulse oximetry and supplemental oxygen Following hand and supplemental oxygen Following hand off report to staff patient left in hospital off report to staff patient left in hospital bed with rails up and staff in attendancebed with rails up and staff in attendance
C H A R TC H A R T
Chief ComplaintChief Complaint HistoryHistory AllergiesAllergies Rx-TreatmentRx-Treatment TransportTransport
(C) Chief Complaint(C) Chief Complaint
Medic 27 responded emergent on a 39 year old female who had a syncope from the standing position
(H) History Present Illness(H) History Present Illness
HPI (history of present illnessinjury) PMH (past medical history) PQRST AMPLE MOI Onset Signs and Symptoms
(A) Assessment(A) Assessment
Include both negative and positive findings Responses the patient has to your
assessment such as the presence or lack of pain andor the presence or lack of sensation
Diagnostic Testing ECG Pulse Oximetry Capnography Blood Glucose Monitoring
(R) Rx-Treatment(R) Rx-Treatment
Document your treatmentDocument your treatment Responses from the Patient to RxResponses from the Patient to Rx Changes in Patients conditionChanges in Patients condition
Example Example ldquoPain decreased to 510 from ldquoPain decreased to 510 from 710 after NTG administered710 after NTG administered
(T) Transport(T) Transport
Where did you goWhere did you go Change in condition during Change in condition during
transporttransport Alteration from ProtocolAlteration from Protocol Who did you turn care over to Who did you turn care over to
(Name if Possible) Ie RN Robinson(Name if Possible) Ie RN Robinson Patency of airway and IV fluidsPatency of airway and IV fluids
CHRONOLOGICALCHRONOLOGICAL
ldquoldquoWrite like your brain thinks itrdquoWrite like your brain thinks itrdquo
Dispatched non-emergent to University Hospitals Dispatched non-emergent to University Hospitals Emergency Educations center for a transport to Emergency Educations center for a transport to UW ER Arrived on floor and met by staff who UW ER Arrived on floor and met by staff who advised us that the patient was suffering from advised us that the patient was suffering from severe PES (Paramedic Education Syndrome) severe PES (Paramedic Education Syndrome) Patient is Mr D a 48 yo male with hx of PES and Patient is Mr D a 48 yo male with hx of PES and CHF who presented with chest pain and CHF who presented with chest pain and dyspneahellipdyspneahellip
Errors and FalsificationsErrors and Falsifications
Avoid ErrorsAvoid Errors Admit when you made a mistakeAdmit when you made a mistake
Revise if necessaryRevise if necessary Note date and time of revisionNote date and time of revision Keep original documentKeep original document Include purpose of the revisionInclude purpose of the revision Only the original author can make the Only the original author can make the
correctioncorrection
Errors and FalsificationsErrors and Falsifications
Always be honest and through in your Always be honest and through in your documentationdocumentation
CorrectionsCorrections Add a supplement on electronic reportsAdd a supplement on electronic reports One line across the error initial the One line across the error initial the
mistake and make the corrections on mistake and make the corrections on written reportswritten reports
Complete reports as soon as possible Complete reports as soon as possible Lost reports have HUGE legal implicationsLost reports have HUGE legal implications Dont keep copies of your reportsDont keep copies of your reports
HIPPAHIPPA
What Happens on What Happens on the Ambulance the Ambulance stays on the stays on the ambulance ambulance
Health Health InsuranceInsurance PortabilityPortability PrivacyPrivacy AccountabilityAccountability
HIPPAHIPPA
Protects the security and privacy of Protects the security and privacy of all medical records and other health all medical records and other health information used or shared in any information used or shared in any formform
Protects patients rights by giving Protects patients rights by giving access to health information and access to health information and control over how it is usedcontrol over how it is used
PHIPHI Protected Heath InformationProtected Heath Information
Information that relates toInformation that relates to The health of an individualThe health of an individual Health care provided to that individualHealth care provided to that individual Payment of heath care providedPayment of heath care provided
What can be sharedWhat can be shared
Health Insurance Company my need Health Insurance Company my need information to process a claiminformation to process a claim
Caregivers involved with direct care Caregivers involved with direct care Quality Assurance when necessaryQuality Assurance when necessary
Special ConsiderationsSpecial Considerations
Exposure and InjuryExposure and Injury Mass CasualtyMass Casualty Interfacility TransportsInterfacility Transports RefusalsRefusals
Mass Casualty EventsMass Casualty Events
Documentation may have to be Documentation may have to be postponedpostponed
Follow Local Policy and ProcedureFollow Local Policy and Procedure Comprehensive run report must be Comprehensive run report must be
completed for each patient when completed for each patient when time permitstime permits
Refusal of CareRefusal of Care
Potential for LiabilityPotential for Liability Good DocumentationGood Documentation Make it clearMake it clear
Refusal of CareRefusal of Care
The litigation rate for EMS has been steadily increasing
1048657 According to one study patients evaluatedby paramedics but not transported to thehospital account for 50 to 90 of EMSlawsuitsrdquo
1048657 Documentation is your best defenserdquo
DocumentationDocumentation
Physical FindingsPhysical Findings The advice you give the patient about The advice you give the patient about
being transported and the associated being transported and the associated risks for not being transportedrisks for not being transported
Clinical indications that patient is Clinical indications that patient is competent to make a rational decisioncompetent to make a rational decision
Signatures of the patient and witnessSignatures of the patient and witness Full narrativeFull narrative Advise to call 911 if condition changesAdvise to call 911 if condition changes
Do not at any time attempt to talk the patient out of going to the hospital
If you feel strongly that the patient should be seen make every attempt to convince them they should be seen
Donrsquot say lsquo I agree you donrsquot need to gordquo even if you agree
What not to sayWhat not to say
A patient suffers a diabetic emergency She is treated by the local EMS crew with an A patient suffers a diabetic emergency She is treated by the local EMS crew with an IV an ampule of D50 and transported to the closet hospital despite family members IV an ampule of D50 and transported to the closet hospital despite family members telling you that the patient does not go theretelling you that the patient does not go there
Transport is uneventful and care is turned over to the ED Nurse with a quick verbal Transport is uneventful and care is turned over to the ED Nurse with a quick verbal reportreport
An hour later a private ambulance is called to transport the patient to her desired An hour later a private ambulance is called to transport the patient to her desired hospital for definitive care They notice the IV has infiltrated and D50 got into her hospital for definitive care They notice the IV has infiltrated and D50 got into her surrounding tissuessurrounding tissues
The patient suffers significant tissue damage which requires a fasciotomy to The patient suffers significant tissue damage which requires a fasciotomy to decompress her hand and forearm She has permanent nerve damage and requires decompress her hand and forearm She has permanent nerve damage and requires skin graftingskin grafting
Initial Transport Agency-CFDInitial Transport Agency-CFD
First Receiving Hospital-St Anthony HospitalFirst Receiving Hospital-St Anthony Hospital
Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998
Lets Finish upLets Finish up
Be ProfessionalBe Professional AccurateAccurate ConsistentConsistent ThroughThrough ClearClear BriefBrief Paint the PicturePaint the Picture CollaborativeCollaborative
Legible spelling Legible spelling correctcorrect
Tell the TruthTell the Truth Donrsquot duplicate infoDonrsquot duplicate info Follow ProtocolsFollow Protocols Plain LanguagePlain Language Relevant InformationRelevant Information ldquoldquoThe JURYrdquoThe JURYrdquo Have your partner Have your partner
reviewreview
My WayMy Way
Level of ConsciousnessLevel of Consciousness Airway Breathing CirculationAirway Breathing Circulation Skin color and tempSkin color and temp Head to Toe ExamHead to Toe Exam Pertinent NegativePertinent Negative
(A) Assessment (What do you think)(A) Assessment (What do you think)
Patient transported to Hospital with seizure Patient transported to Hospital with seizure like activitylike activity
Not a diagnosisNot a diagnosis
Protocol FollowedProtocol Followed
(P) Plan What did you do(P) Plan What did you do
Patient transported non-emergent to Aurora Patient transported non-emergent to Aurora Medical Center emergency room Patient Medical Center emergency room Patient transported without change in status or transported without change in status or
level of consciousness Patients treatment level of consciousness Patients treatment plan included full secondary assessment plan included full secondary assessment detailed neurological examination vital detailed neurological examination vital
signs cardiac monitoring pulse oximetry signs cardiac monitoring pulse oximetry and supplemental oxygen Following hand and supplemental oxygen Following hand off report to staff patient left in hospital off report to staff patient left in hospital bed with rails up and staff in attendancebed with rails up and staff in attendance
C H A R TC H A R T
Chief ComplaintChief Complaint HistoryHistory AllergiesAllergies Rx-TreatmentRx-Treatment TransportTransport
(C) Chief Complaint(C) Chief Complaint
Medic 27 responded emergent on a 39 year old female who had a syncope from the standing position
(H) History Present Illness(H) History Present Illness
HPI (history of present illnessinjury) PMH (past medical history) PQRST AMPLE MOI Onset Signs and Symptoms
(A) Assessment(A) Assessment
Include both negative and positive findings Responses the patient has to your
assessment such as the presence or lack of pain andor the presence or lack of sensation
Diagnostic Testing ECG Pulse Oximetry Capnography Blood Glucose Monitoring
(R) Rx-Treatment(R) Rx-Treatment
Document your treatmentDocument your treatment Responses from the Patient to RxResponses from the Patient to Rx Changes in Patients conditionChanges in Patients condition
Example Example ldquoPain decreased to 510 from ldquoPain decreased to 510 from 710 after NTG administered710 after NTG administered
(T) Transport(T) Transport
Where did you goWhere did you go Change in condition during Change in condition during
transporttransport Alteration from ProtocolAlteration from Protocol Who did you turn care over to Who did you turn care over to
(Name if Possible) Ie RN Robinson(Name if Possible) Ie RN Robinson Patency of airway and IV fluidsPatency of airway and IV fluids
CHRONOLOGICALCHRONOLOGICAL
ldquoldquoWrite like your brain thinks itrdquoWrite like your brain thinks itrdquo
Dispatched non-emergent to University Hospitals Dispatched non-emergent to University Hospitals Emergency Educations center for a transport to Emergency Educations center for a transport to UW ER Arrived on floor and met by staff who UW ER Arrived on floor and met by staff who advised us that the patient was suffering from advised us that the patient was suffering from severe PES (Paramedic Education Syndrome) severe PES (Paramedic Education Syndrome) Patient is Mr D a 48 yo male with hx of PES and Patient is Mr D a 48 yo male with hx of PES and CHF who presented with chest pain and CHF who presented with chest pain and dyspneahellipdyspneahellip
Errors and FalsificationsErrors and Falsifications
Avoid ErrorsAvoid Errors Admit when you made a mistakeAdmit when you made a mistake
Revise if necessaryRevise if necessary Note date and time of revisionNote date and time of revision Keep original documentKeep original document Include purpose of the revisionInclude purpose of the revision Only the original author can make the Only the original author can make the
correctioncorrection
Errors and FalsificationsErrors and Falsifications
Always be honest and through in your Always be honest and through in your documentationdocumentation
CorrectionsCorrections Add a supplement on electronic reportsAdd a supplement on electronic reports One line across the error initial the One line across the error initial the
mistake and make the corrections on mistake and make the corrections on written reportswritten reports
Complete reports as soon as possible Complete reports as soon as possible Lost reports have HUGE legal implicationsLost reports have HUGE legal implications Dont keep copies of your reportsDont keep copies of your reports
HIPPAHIPPA
What Happens on What Happens on the Ambulance the Ambulance stays on the stays on the ambulance ambulance
Health Health InsuranceInsurance PortabilityPortability PrivacyPrivacy AccountabilityAccountability
HIPPAHIPPA
Protects the security and privacy of Protects the security and privacy of all medical records and other health all medical records and other health information used or shared in any information used or shared in any formform
Protects patients rights by giving Protects patients rights by giving access to health information and access to health information and control over how it is usedcontrol over how it is used
PHIPHI Protected Heath InformationProtected Heath Information
Information that relates toInformation that relates to The health of an individualThe health of an individual Health care provided to that individualHealth care provided to that individual Payment of heath care providedPayment of heath care provided
What can be sharedWhat can be shared
Health Insurance Company my need Health Insurance Company my need information to process a claiminformation to process a claim
Caregivers involved with direct care Caregivers involved with direct care Quality Assurance when necessaryQuality Assurance when necessary
Special ConsiderationsSpecial Considerations
Exposure and InjuryExposure and Injury Mass CasualtyMass Casualty Interfacility TransportsInterfacility Transports RefusalsRefusals
Mass Casualty EventsMass Casualty Events
Documentation may have to be Documentation may have to be postponedpostponed
Follow Local Policy and ProcedureFollow Local Policy and Procedure Comprehensive run report must be Comprehensive run report must be
completed for each patient when completed for each patient when time permitstime permits
Refusal of CareRefusal of Care
Potential for LiabilityPotential for Liability Good DocumentationGood Documentation Make it clearMake it clear
Refusal of CareRefusal of Care
The litigation rate for EMS has been steadily increasing
1048657 According to one study patients evaluatedby paramedics but not transported to thehospital account for 50 to 90 of EMSlawsuitsrdquo
1048657 Documentation is your best defenserdquo
DocumentationDocumentation
Physical FindingsPhysical Findings The advice you give the patient about The advice you give the patient about
being transported and the associated being transported and the associated risks for not being transportedrisks for not being transported
Clinical indications that patient is Clinical indications that patient is competent to make a rational decisioncompetent to make a rational decision
Signatures of the patient and witnessSignatures of the patient and witness Full narrativeFull narrative Advise to call 911 if condition changesAdvise to call 911 if condition changes
Do not at any time attempt to talk the patient out of going to the hospital
If you feel strongly that the patient should be seen make every attempt to convince them they should be seen
Donrsquot say lsquo I agree you donrsquot need to gordquo even if you agree
What not to sayWhat not to say
A patient suffers a diabetic emergency She is treated by the local EMS crew with an A patient suffers a diabetic emergency She is treated by the local EMS crew with an IV an ampule of D50 and transported to the closet hospital despite family members IV an ampule of D50 and transported to the closet hospital despite family members telling you that the patient does not go theretelling you that the patient does not go there
Transport is uneventful and care is turned over to the ED Nurse with a quick verbal Transport is uneventful and care is turned over to the ED Nurse with a quick verbal reportreport
An hour later a private ambulance is called to transport the patient to her desired An hour later a private ambulance is called to transport the patient to her desired hospital for definitive care They notice the IV has infiltrated and D50 got into her hospital for definitive care They notice the IV has infiltrated and D50 got into her surrounding tissuessurrounding tissues
The patient suffers significant tissue damage which requires a fasciotomy to The patient suffers significant tissue damage which requires a fasciotomy to decompress her hand and forearm She has permanent nerve damage and requires decompress her hand and forearm She has permanent nerve damage and requires skin graftingskin grafting
Initial Transport Agency-CFDInitial Transport Agency-CFD
First Receiving Hospital-St Anthony HospitalFirst Receiving Hospital-St Anthony Hospital
Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998
Lets Finish upLets Finish up
Be ProfessionalBe Professional AccurateAccurate ConsistentConsistent ThroughThrough ClearClear BriefBrief Paint the PicturePaint the Picture CollaborativeCollaborative
Legible spelling Legible spelling correctcorrect
Tell the TruthTell the Truth Donrsquot duplicate infoDonrsquot duplicate info Follow ProtocolsFollow Protocols Plain LanguagePlain Language Relevant InformationRelevant Information ldquoldquoThe JURYrdquoThe JURYrdquo Have your partner Have your partner
reviewreview
(A) Assessment (What do you think)(A) Assessment (What do you think)
Patient transported to Hospital with seizure Patient transported to Hospital with seizure like activitylike activity
Not a diagnosisNot a diagnosis
Protocol FollowedProtocol Followed
(P) Plan What did you do(P) Plan What did you do
Patient transported non-emergent to Aurora Patient transported non-emergent to Aurora Medical Center emergency room Patient Medical Center emergency room Patient transported without change in status or transported without change in status or
level of consciousness Patients treatment level of consciousness Patients treatment plan included full secondary assessment plan included full secondary assessment detailed neurological examination vital detailed neurological examination vital
signs cardiac monitoring pulse oximetry signs cardiac monitoring pulse oximetry and supplemental oxygen Following hand and supplemental oxygen Following hand off report to staff patient left in hospital off report to staff patient left in hospital bed with rails up and staff in attendancebed with rails up and staff in attendance
C H A R TC H A R T
Chief ComplaintChief Complaint HistoryHistory AllergiesAllergies Rx-TreatmentRx-Treatment TransportTransport
(C) Chief Complaint(C) Chief Complaint
Medic 27 responded emergent on a 39 year old female who had a syncope from the standing position
(H) History Present Illness(H) History Present Illness
HPI (history of present illnessinjury) PMH (past medical history) PQRST AMPLE MOI Onset Signs and Symptoms
(A) Assessment(A) Assessment
Include both negative and positive findings Responses the patient has to your
assessment such as the presence or lack of pain andor the presence or lack of sensation
Diagnostic Testing ECG Pulse Oximetry Capnography Blood Glucose Monitoring
(R) Rx-Treatment(R) Rx-Treatment
Document your treatmentDocument your treatment Responses from the Patient to RxResponses from the Patient to Rx Changes in Patients conditionChanges in Patients condition
Example Example ldquoPain decreased to 510 from ldquoPain decreased to 510 from 710 after NTG administered710 after NTG administered
(T) Transport(T) Transport
Where did you goWhere did you go Change in condition during Change in condition during
transporttransport Alteration from ProtocolAlteration from Protocol Who did you turn care over to Who did you turn care over to
(Name if Possible) Ie RN Robinson(Name if Possible) Ie RN Robinson Patency of airway and IV fluidsPatency of airway and IV fluids
CHRONOLOGICALCHRONOLOGICAL
ldquoldquoWrite like your brain thinks itrdquoWrite like your brain thinks itrdquo
Dispatched non-emergent to University Hospitals Dispatched non-emergent to University Hospitals Emergency Educations center for a transport to Emergency Educations center for a transport to UW ER Arrived on floor and met by staff who UW ER Arrived on floor and met by staff who advised us that the patient was suffering from advised us that the patient was suffering from severe PES (Paramedic Education Syndrome) severe PES (Paramedic Education Syndrome) Patient is Mr D a 48 yo male with hx of PES and Patient is Mr D a 48 yo male with hx of PES and CHF who presented with chest pain and CHF who presented with chest pain and dyspneahellipdyspneahellip
Errors and FalsificationsErrors and Falsifications
Avoid ErrorsAvoid Errors Admit when you made a mistakeAdmit when you made a mistake
Revise if necessaryRevise if necessary Note date and time of revisionNote date and time of revision Keep original documentKeep original document Include purpose of the revisionInclude purpose of the revision Only the original author can make the Only the original author can make the
correctioncorrection
Errors and FalsificationsErrors and Falsifications
Always be honest and through in your Always be honest and through in your documentationdocumentation
CorrectionsCorrections Add a supplement on electronic reportsAdd a supplement on electronic reports One line across the error initial the One line across the error initial the
mistake and make the corrections on mistake and make the corrections on written reportswritten reports
Complete reports as soon as possible Complete reports as soon as possible Lost reports have HUGE legal implicationsLost reports have HUGE legal implications Dont keep copies of your reportsDont keep copies of your reports
HIPPAHIPPA
What Happens on What Happens on the Ambulance the Ambulance stays on the stays on the ambulance ambulance
Health Health InsuranceInsurance PortabilityPortability PrivacyPrivacy AccountabilityAccountability
HIPPAHIPPA
Protects the security and privacy of Protects the security and privacy of all medical records and other health all medical records and other health information used or shared in any information used or shared in any formform
Protects patients rights by giving Protects patients rights by giving access to health information and access to health information and control over how it is usedcontrol over how it is used
PHIPHI Protected Heath InformationProtected Heath Information
Information that relates toInformation that relates to The health of an individualThe health of an individual Health care provided to that individualHealth care provided to that individual Payment of heath care providedPayment of heath care provided
What can be sharedWhat can be shared
Health Insurance Company my need Health Insurance Company my need information to process a claiminformation to process a claim
Caregivers involved with direct care Caregivers involved with direct care Quality Assurance when necessaryQuality Assurance when necessary
Special ConsiderationsSpecial Considerations
Exposure and InjuryExposure and Injury Mass CasualtyMass Casualty Interfacility TransportsInterfacility Transports RefusalsRefusals
Mass Casualty EventsMass Casualty Events
Documentation may have to be Documentation may have to be postponedpostponed
Follow Local Policy and ProcedureFollow Local Policy and Procedure Comprehensive run report must be Comprehensive run report must be
completed for each patient when completed for each patient when time permitstime permits
Refusal of CareRefusal of Care
Potential for LiabilityPotential for Liability Good DocumentationGood Documentation Make it clearMake it clear
Refusal of CareRefusal of Care
The litigation rate for EMS has been steadily increasing
1048657 According to one study patients evaluatedby paramedics but not transported to thehospital account for 50 to 90 of EMSlawsuitsrdquo
1048657 Documentation is your best defenserdquo
DocumentationDocumentation
Physical FindingsPhysical Findings The advice you give the patient about The advice you give the patient about
being transported and the associated being transported and the associated risks for not being transportedrisks for not being transported
Clinical indications that patient is Clinical indications that patient is competent to make a rational decisioncompetent to make a rational decision
Signatures of the patient and witnessSignatures of the patient and witness Full narrativeFull narrative Advise to call 911 if condition changesAdvise to call 911 if condition changes
Do not at any time attempt to talk the patient out of going to the hospital
If you feel strongly that the patient should be seen make every attempt to convince them they should be seen
Donrsquot say lsquo I agree you donrsquot need to gordquo even if you agree
What not to sayWhat not to say
A patient suffers a diabetic emergency She is treated by the local EMS crew with an A patient suffers a diabetic emergency She is treated by the local EMS crew with an IV an ampule of D50 and transported to the closet hospital despite family members IV an ampule of D50 and transported to the closet hospital despite family members telling you that the patient does not go theretelling you that the patient does not go there
Transport is uneventful and care is turned over to the ED Nurse with a quick verbal Transport is uneventful and care is turned over to the ED Nurse with a quick verbal reportreport
An hour later a private ambulance is called to transport the patient to her desired An hour later a private ambulance is called to transport the patient to her desired hospital for definitive care They notice the IV has infiltrated and D50 got into her hospital for definitive care They notice the IV has infiltrated and D50 got into her surrounding tissuessurrounding tissues
The patient suffers significant tissue damage which requires a fasciotomy to The patient suffers significant tissue damage which requires a fasciotomy to decompress her hand and forearm She has permanent nerve damage and requires decompress her hand and forearm She has permanent nerve damage and requires skin graftingskin grafting
Initial Transport Agency-CFDInitial Transport Agency-CFD
First Receiving Hospital-St Anthony HospitalFirst Receiving Hospital-St Anthony Hospital
Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998
Lets Finish upLets Finish up
Be ProfessionalBe Professional AccurateAccurate ConsistentConsistent ThroughThrough ClearClear BriefBrief Paint the PicturePaint the Picture CollaborativeCollaborative
Legible spelling Legible spelling correctcorrect
Tell the TruthTell the Truth Donrsquot duplicate infoDonrsquot duplicate info Follow ProtocolsFollow Protocols Plain LanguagePlain Language Relevant InformationRelevant Information ldquoldquoThe JURYrdquoThe JURYrdquo Have your partner Have your partner
reviewreview
(P) Plan What did you do(P) Plan What did you do
Patient transported non-emergent to Aurora Patient transported non-emergent to Aurora Medical Center emergency room Patient Medical Center emergency room Patient transported without change in status or transported without change in status or
level of consciousness Patients treatment level of consciousness Patients treatment plan included full secondary assessment plan included full secondary assessment detailed neurological examination vital detailed neurological examination vital
signs cardiac monitoring pulse oximetry signs cardiac monitoring pulse oximetry and supplemental oxygen Following hand and supplemental oxygen Following hand off report to staff patient left in hospital off report to staff patient left in hospital bed with rails up and staff in attendancebed with rails up and staff in attendance
C H A R TC H A R T
Chief ComplaintChief Complaint HistoryHistory AllergiesAllergies Rx-TreatmentRx-Treatment TransportTransport
(C) Chief Complaint(C) Chief Complaint
Medic 27 responded emergent on a 39 year old female who had a syncope from the standing position
(H) History Present Illness(H) History Present Illness
HPI (history of present illnessinjury) PMH (past medical history) PQRST AMPLE MOI Onset Signs and Symptoms
(A) Assessment(A) Assessment
Include both negative and positive findings Responses the patient has to your
assessment such as the presence or lack of pain andor the presence or lack of sensation
Diagnostic Testing ECG Pulse Oximetry Capnography Blood Glucose Monitoring
(R) Rx-Treatment(R) Rx-Treatment
Document your treatmentDocument your treatment Responses from the Patient to RxResponses from the Patient to Rx Changes in Patients conditionChanges in Patients condition
Example Example ldquoPain decreased to 510 from ldquoPain decreased to 510 from 710 after NTG administered710 after NTG administered
(T) Transport(T) Transport
Where did you goWhere did you go Change in condition during Change in condition during
transporttransport Alteration from ProtocolAlteration from Protocol Who did you turn care over to Who did you turn care over to
(Name if Possible) Ie RN Robinson(Name if Possible) Ie RN Robinson Patency of airway and IV fluidsPatency of airway and IV fluids
CHRONOLOGICALCHRONOLOGICAL
ldquoldquoWrite like your brain thinks itrdquoWrite like your brain thinks itrdquo
Dispatched non-emergent to University Hospitals Dispatched non-emergent to University Hospitals Emergency Educations center for a transport to Emergency Educations center for a transport to UW ER Arrived on floor and met by staff who UW ER Arrived on floor and met by staff who advised us that the patient was suffering from advised us that the patient was suffering from severe PES (Paramedic Education Syndrome) severe PES (Paramedic Education Syndrome) Patient is Mr D a 48 yo male with hx of PES and Patient is Mr D a 48 yo male with hx of PES and CHF who presented with chest pain and CHF who presented with chest pain and dyspneahellipdyspneahellip
Errors and FalsificationsErrors and Falsifications
Avoid ErrorsAvoid Errors Admit when you made a mistakeAdmit when you made a mistake
Revise if necessaryRevise if necessary Note date and time of revisionNote date and time of revision Keep original documentKeep original document Include purpose of the revisionInclude purpose of the revision Only the original author can make the Only the original author can make the
correctioncorrection
Errors and FalsificationsErrors and Falsifications
Always be honest and through in your Always be honest and through in your documentationdocumentation
CorrectionsCorrections Add a supplement on electronic reportsAdd a supplement on electronic reports One line across the error initial the One line across the error initial the
mistake and make the corrections on mistake and make the corrections on written reportswritten reports
Complete reports as soon as possible Complete reports as soon as possible Lost reports have HUGE legal implicationsLost reports have HUGE legal implications Dont keep copies of your reportsDont keep copies of your reports
HIPPAHIPPA
What Happens on What Happens on the Ambulance the Ambulance stays on the stays on the ambulance ambulance
Health Health InsuranceInsurance PortabilityPortability PrivacyPrivacy AccountabilityAccountability
HIPPAHIPPA
Protects the security and privacy of Protects the security and privacy of all medical records and other health all medical records and other health information used or shared in any information used or shared in any formform
Protects patients rights by giving Protects patients rights by giving access to health information and access to health information and control over how it is usedcontrol over how it is used
PHIPHI Protected Heath InformationProtected Heath Information
Information that relates toInformation that relates to The health of an individualThe health of an individual Health care provided to that individualHealth care provided to that individual Payment of heath care providedPayment of heath care provided
What can be sharedWhat can be shared
Health Insurance Company my need Health Insurance Company my need information to process a claiminformation to process a claim
Caregivers involved with direct care Caregivers involved with direct care Quality Assurance when necessaryQuality Assurance when necessary
Special ConsiderationsSpecial Considerations
Exposure and InjuryExposure and Injury Mass CasualtyMass Casualty Interfacility TransportsInterfacility Transports RefusalsRefusals
Mass Casualty EventsMass Casualty Events
Documentation may have to be Documentation may have to be postponedpostponed
Follow Local Policy and ProcedureFollow Local Policy and Procedure Comprehensive run report must be Comprehensive run report must be
completed for each patient when completed for each patient when time permitstime permits
Refusal of CareRefusal of Care
Potential for LiabilityPotential for Liability Good DocumentationGood Documentation Make it clearMake it clear
Refusal of CareRefusal of Care
The litigation rate for EMS has been steadily increasing
1048657 According to one study patients evaluatedby paramedics but not transported to thehospital account for 50 to 90 of EMSlawsuitsrdquo
1048657 Documentation is your best defenserdquo
DocumentationDocumentation
Physical FindingsPhysical Findings The advice you give the patient about The advice you give the patient about
being transported and the associated being transported and the associated risks for not being transportedrisks for not being transported
Clinical indications that patient is Clinical indications that patient is competent to make a rational decisioncompetent to make a rational decision
Signatures of the patient and witnessSignatures of the patient and witness Full narrativeFull narrative Advise to call 911 if condition changesAdvise to call 911 if condition changes
Do not at any time attempt to talk the patient out of going to the hospital
If you feel strongly that the patient should be seen make every attempt to convince them they should be seen
Donrsquot say lsquo I agree you donrsquot need to gordquo even if you agree
What not to sayWhat not to say
A patient suffers a diabetic emergency She is treated by the local EMS crew with an A patient suffers a diabetic emergency She is treated by the local EMS crew with an IV an ampule of D50 and transported to the closet hospital despite family members IV an ampule of D50 and transported to the closet hospital despite family members telling you that the patient does not go theretelling you that the patient does not go there
Transport is uneventful and care is turned over to the ED Nurse with a quick verbal Transport is uneventful and care is turned over to the ED Nurse with a quick verbal reportreport
An hour later a private ambulance is called to transport the patient to her desired An hour later a private ambulance is called to transport the patient to her desired hospital for definitive care They notice the IV has infiltrated and D50 got into her hospital for definitive care They notice the IV has infiltrated and D50 got into her surrounding tissuessurrounding tissues
The patient suffers significant tissue damage which requires a fasciotomy to The patient suffers significant tissue damage which requires a fasciotomy to decompress her hand and forearm She has permanent nerve damage and requires decompress her hand and forearm She has permanent nerve damage and requires skin graftingskin grafting
Initial Transport Agency-CFDInitial Transport Agency-CFD
First Receiving Hospital-St Anthony HospitalFirst Receiving Hospital-St Anthony Hospital
Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998
Lets Finish upLets Finish up
Be ProfessionalBe Professional AccurateAccurate ConsistentConsistent ThroughThrough ClearClear BriefBrief Paint the PicturePaint the Picture CollaborativeCollaborative
Legible spelling Legible spelling correctcorrect
Tell the TruthTell the Truth Donrsquot duplicate infoDonrsquot duplicate info Follow ProtocolsFollow Protocols Plain LanguagePlain Language Relevant InformationRelevant Information ldquoldquoThe JURYrdquoThe JURYrdquo Have your partner Have your partner
reviewreview
C H A R TC H A R T
Chief ComplaintChief Complaint HistoryHistory AllergiesAllergies Rx-TreatmentRx-Treatment TransportTransport
(C) Chief Complaint(C) Chief Complaint
Medic 27 responded emergent on a 39 year old female who had a syncope from the standing position
(H) History Present Illness(H) History Present Illness
HPI (history of present illnessinjury) PMH (past medical history) PQRST AMPLE MOI Onset Signs and Symptoms
(A) Assessment(A) Assessment
Include both negative and positive findings Responses the patient has to your
assessment such as the presence or lack of pain andor the presence or lack of sensation
Diagnostic Testing ECG Pulse Oximetry Capnography Blood Glucose Monitoring
(R) Rx-Treatment(R) Rx-Treatment
Document your treatmentDocument your treatment Responses from the Patient to RxResponses from the Patient to Rx Changes in Patients conditionChanges in Patients condition
Example Example ldquoPain decreased to 510 from ldquoPain decreased to 510 from 710 after NTG administered710 after NTG administered
(T) Transport(T) Transport
Where did you goWhere did you go Change in condition during Change in condition during
transporttransport Alteration from ProtocolAlteration from Protocol Who did you turn care over to Who did you turn care over to
(Name if Possible) Ie RN Robinson(Name if Possible) Ie RN Robinson Patency of airway and IV fluidsPatency of airway and IV fluids
CHRONOLOGICALCHRONOLOGICAL
ldquoldquoWrite like your brain thinks itrdquoWrite like your brain thinks itrdquo
Dispatched non-emergent to University Hospitals Dispatched non-emergent to University Hospitals Emergency Educations center for a transport to Emergency Educations center for a transport to UW ER Arrived on floor and met by staff who UW ER Arrived on floor and met by staff who advised us that the patient was suffering from advised us that the patient was suffering from severe PES (Paramedic Education Syndrome) severe PES (Paramedic Education Syndrome) Patient is Mr D a 48 yo male with hx of PES and Patient is Mr D a 48 yo male with hx of PES and CHF who presented with chest pain and CHF who presented with chest pain and dyspneahellipdyspneahellip
Errors and FalsificationsErrors and Falsifications
Avoid ErrorsAvoid Errors Admit when you made a mistakeAdmit when you made a mistake
Revise if necessaryRevise if necessary Note date and time of revisionNote date and time of revision Keep original documentKeep original document Include purpose of the revisionInclude purpose of the revision Only the original author can make the Only the original author can make the
correctioncorrection
Errors and FalsificationsErrors and Falsifications
Always be honest and through in your Always be honest and through in your documentationdocumentation
CorrectionsCorrections Add a supplement on electronic reportsAdd a supplement on electronic reports One line across the error initial the One line across the error initial the
mistake and make the corrections on mistake and make the corrections on written reportswritten reports
Complete reports as soon as possible Complete reports as soon as possible Lost reports have HUGE legal implicationsLost reports have HUGE legal implications Dont keep copies of your reportsDont keep copies of your reports
HIPPAHIPPA
What Happens on What Happens on the Ambulance the Ambulance stays on the stays on the ambulance ambulance
Health Health InsuranceInsurance PortabilityPortability PrivacyPrivacy AccountabilityAccountability
HIPPAHIPPA
Protects the security and privacy of Protects the security and privacy of all medical records and other health all medical records and other health information used or shared in any information used or shared in any formform
Protects patients rights by giving Protects patients rights by giving access to health information and access to health information and control over how it is usedcontrol over how it is used
PHIPHI Protected Heath InformationProtected Heath Information
Information that relates toInformation that relates to The health of an individualThe health of an individual Health care provided to that individualHealth care provided to that individual Payment of heath care providedPayment of heath care provided
What can be sharedWhat can be shared
Health Insurance Company my need Health Insurance Company my need information to process a claiminformation to process a claim
Caregivers involved with direct care Caregivers involved with direct care Quality Assurance when necessaryQuality Assurance when necessary
Special ConsiderationsSpecial Considerations
Exposure and InjuryExposure and Injury Mass CasualtyMass Casualty Interfacility TransportsInterfacility Transports RefusalsRefusals
Mass Casualty EventsMass Casualty Events
Documentation may have to be Documentation may have to be postponedpostponed
Follow Local Policy and ProcedureFollow Local Policy and Procedure Comprehensive run report must be Comprehensive run report must be
completed for each patient when completed for each patient when time permitstime permits
Refusal of CareRefusal of Care
Potential for LiabilityPotential for Liability Good DocumentationGood Documentation Make it clearMake it clear
Refusal of CareRefusal of Care
The litigation rate for EMS has been steadily increasing
1048657 According to one study patients evaluatedby paramedics but not transported to thehospital account for 50 to 90 of EMSlawsuitsrdquo
1048657 Documentation is your best defenserdquo
DocumentationDocumentation
Physical FindingsPhysical Findings The advice you give the patient about The advice you give the patient about
being transported and the associated being transported and the associated risks for not being transportedrisks for not being transported
Clinical indications that patient is Clinical indications that patient is competent to make a rational decisioncompetent to make a rational decision
Signatures of the patient and witnessSignatures of the patient and witness Full narrativeFull narrative Advise to call 911 if condition changesAdvise to call 911 if condition changes
Do not at any time attempt to talk the patient out of going to the hospital
If you feel strongly that the patient should be seen make every attempt to convince them they should be seen
Donrsquot say lsquo I agree you donrsquot need to gordquo even if you agree
What not to sayWhat not to say
A patient suffers a diabetic emergency She is treated by the local EMS crew with an A patient suffers a diabetic emergency She is treated by the local EMS crew with an IV an ampule of D50 and transported to the closet hospital despite family members IV an ampule of D50 and transported to the closet hospital despite family members telling you that the patient does not go theretelling you that the patient does not go there
Transport is uneventful and care is turned over to the ED Nurse with a quick verbal Transport is uneventful and care is turned over to the ED Nurse with a quick verbal reportreport
An hour later a private ambulance is called to transport the patient to her desired An hour later a private ambulance is called to transport the patient to her desired hospital for definitive care They notice the IV has infiltrated and D50 got into her hospital for definitive care They notice the IV has infiltrated and D50 got into her surrounding tissuessurrounding tissues
The patient suffers significant tissue damage which requires a fasciotomy to The patient suffers significant tissue damage which requires a fasciotomy to decompress her hand and forearm She has permanent nerve damage and requires decompress her hand and forearm She has permanent nerve damage and requires skin graftingskin grafting
Initial Transport Agency-CFDInitial Transport Agency-CFD
First Receiving Hospital-St Anthony HospitalFirst Receiving Hospital-St Anthony Hospital
Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998
Lets Finish upLets Finish up
Be ProfessionalBe Professional AccurateAccurate ConsistentConsistent ThroughThrough ClearClear BriefBrief Paint the PicturePaint the Picture CollaborativeCollaborative
Legible spelling Legible spelling correctcorrect
Tell the TruthTell the Truth Donrsquot duplicate infoDonrsquot duplicate info Follow ProtocolsFollow Protocols Plain LanguagePlain Language Relevant InformationRelevant Information ldquoldquoThe JURYrdquoThe JURYrdquo Have your partner Have your partner
reviewreview
(C) Chief Complaint(C) Chief Complaint
Medic 27 responded emergent on a 39 year old female who had a syncope from the standing position
(H) History Present Illness(H) History Present Illness
HPI (history of present illnessinjury) PMH (past medical history) PQRST AMPLE MOI Onset Signs and Symptoms
(A) Assessment(A) Assessment
Include both negative and positive findings Responses the patient has to your
assessment such as the presence or lack of pain andor the presence or lack of sensation
Diagnostic Testing ECG Pulse Oximetry Capnography Blood Glucose Monitoring
(R) Rx-Treatment(R) Rx-Treatment
Document your treatmentDocument your treatment Responses from the Patient to RxResponses from the Patient to Rx Changes in Patients conditionChanges in Patients condition
Example Example ldquoPain decreased to 510 from ldquoPain decreased to 510 from 710 after NTG administered710 after NTG administered
(T) Transport(T) Transport
Where did you goWhere did you go Change in condition during Change in condition during
transporttransport Alteration from ProtocolAlteration from Protocol Who did you turn care over to Who did you turn care over to
(Name if Possible) Ie RN Robinson(Name if Possible) Ie RN Robinson Patency of airway and IV fluidsPatency of airway and IV fluids
CHRONOLOGICALCHRONOLOGICAL
ldquoldquoWrite like your brain thinks itrdquoWrite like your brain thinks itrdquo
Dispatched non-emergent to University Hospitals Dispatched non-emergent to University Hospitals Emergency Educations center for a transport to Emergency Educations center for a transport to UW ER Arrived on floor and met by staff who UW ER Arrived on floor and met by staff who advised us that the patient was suffering from advised us that the patient was suffering from severe PES (Paramedic Education Syndrome) severe PES (Paramedic Education Syndrome) Patient is Mr D a 48 yo male with hx of PES and Patient is Mr D a 48 yo male with hx of PES and CHF who presented with chest pain and CHF who presented with chest pain and dyspneahellipdyspneahellip
Errors and FalsificationsErrors and Falsifications
Avoid ErrorsAvoid Errors Admit when you made a mistakeAdmit when you made a mistake
Revise if necessaryRevise if necessary Note date and time of revisionNote date and time of revision Keep original documentKeep original document Include purpose of the revisionInclude purpose of the revision Only the original author can make the Only the original author can make the
correctioncorrection
Errors and FalsificationsErrors and Falsifications
Always be honest and through in your Always be honest and through in your documentationdocumentation
CorrectionsCorrections Add a supplement on electronic reportsAdd a supplement on electronic reports One line across the error initial the One line across the error initial the
mistake and make the corrections on mistake and make the corrections on written reportswritten reports
Complete reports as soon as possible Complete reports as soon as possible Lost reports have HUGE legal implicationsLost reports have HUGE legal implications Dont keep copies of your reportsDont keep copies of your reports
HIPPAHIPPA
What Happens on What Happens on the Ambulance the Ambulance stays on the stays on the ambulance ambulance
Health Health InsuranceInsurance PortabilityPortability PrivacyPrivacy AccountabilityAccountability
HIPPAHIPPA
Protects the security and privacy of Protects the security and privacy of all medical records and other health all medical records and other health information used or shared in any information used or shared in any formform
Protects patients rights by giving Protects patients rights by giving access to health information and access to health information and control over how it is usedcontrol over how it is used
PHIPHI Protected Heath InformationProtected Heath Information
Information that relates toInformation that relates to The health of an individualThe health of an individual Health care provided to that individualHealth care provided to that individual Payment of heath care providedPayment of heath care provided
What can be sharedWhat can be shared
Health Insurance Company my need Health Insurance Company my need information to process a claiminformation to process a claim
Caregivers involved with direct care Caregivers involved with direct care Quality Assurance when necessaryQuality Assurance when necessary
Special ConsiderationsSpecial Considerations
Exposure and InjuryExposure and Injury Mass CasualtyMass Casualty Interfacility TransportsInterfacility Transports RefusalsRefusals
Mass Casualty EventsMass Casualty Events
Documentation may have to be Documentation may have to be postponedpostponed
Follow Local Policy and ProcedureFollow Local Policy and Procedure Comprehensive run report must be Comprehensive run report must be
completed for each patient when completed for each patient when time permitstime permits
Refusal of CareRefusal of Care
Potential for LiabilityPotential for Liability Good DocumentationGood Documentation Make it clearMake it clear
Refusal of CareRefusal of Care
The litigation rate for EMS has been steadily increasing
1048657 According to one study patients evaluatedby paramedics but not transported to thehospital account for 50 to 90 of EMSlawsuitsrdquo
1048657 Documentation is your best defenserdquo
DocumentationDocumentation
Physical FindingsPhysical Findings The advice you give the patient about The advice you give the patient about
being transported and the associated being transported and the associated risks for not being transportedrisks for not being transported
Clinical indications that patient is Clinical indications that patient is competent to make a rational decisioncompetent to make a rational decision
Signatures of the patient and witnessSignatures of the patient and witness Full narrativeFull narrative Advise to call 911 if condition changesAdvise to call 911 if condition changes
Do not at any time attempt to talk the patient out of going to the hospital
If you feel strongly that the patient should be seen make every attempt to convince them they should be seen
Donrsquot say lsquo I agree you donrsquot need to gordquo even if you agree
What not to sayWhat not to say
A patient suffers a diabetic emergency She is treated by the local EMS crew with an A patient suffers a diabetic emergency She is treated by the local EMS crew with an IV an ampule of D50 and transported to the closet hospital despite family members IV an ampule of D50 and transported to the closet hospital despite family members telling you that the patient does not go theretelling you that the patient does not go there
Transport is uneventful and care is turned over to the ED Nurse with a quick verbal Transport is uneventful and care is turned over to the ED Nurse with a quick verbal reportreport
An hour later a private ambulance is called to transport the patient to her desired An hour later a private ambulance is called to transport the patient to her desired hospital for definitive care They notice the IV has infiltrated and D50 got into her hospital for definitive care They notice the IV has infiltrated and D50 got into her surrounding tissuessurrounding tissues
The patient suffers significant tissue damage which requires a fasciotomy to The patient suffers significant tissue damage which requires a fasciotomy to decompress her hand and forearm She has permanent nerve damage and requires decompress her hand and forearm She has permanent nerve damage and requires skin graftingskin grafting
Initial Transport Agency-CFDInitial Transport Agency-CFD
First Receiving Hospital-St Anthony HospitalFirst Receiving Hospital-St Anthony Hospital
Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998
Lets Finish upLets Finish up
Be ProfessionalBe Professional AccurateAccurate ConsistentConsistent ThroughThrough ClearClear BriefBrief Paint the PicturePaint the Picture CollaborativeCollaborative
Legible spelling Legible spelling correctcorrect
Tell the TruthTell the Truth Donrsquot duplicate infoDonrsquot duplicate info Follow ProtocolsFollow Protocols Plain LanguagePlain Language Relevant InformationRelevant Information ldquoldquoThe JURYrdquoThe JURYrdquo Have your partner Have your partner
reviewreview
(H) History Present Illness(H) History Present Illness
HPI (history of present illnessinjury) PMH (past medical history) PQRST AMPLE MOI Onset Signs and Symptoms
(A) Assessment(A) Assessment
Include both negative and positive findings Responses the patient has to your
assessment such as the presence or lack of pain andor the presence or lack of sensation
Diagnostic Testing ECG Pulse Oximetry Capnography Blood Glucose Monitoring
(R) Rx-Treatment(R) Rx-Treatment
Document your treatmentDocument your treatment Responses from the Patient to RxResponses from the Patient to Rx Changes in Patients conditionChanges in Patients condition
Example Example ldquoPain decreased to 510 from ldquoPain decreased to 510 from 710 after NTG administered710 after NTG administered
(T) Transport(T) Transport
Where did you goWhere did you go Change in condition during Change in condition during
transporttransport Alteration from ProtocolAlteration from Protocol Who did you turn care over to Who did you turn care over to
(Name if Possible) Ie RN Robinson(Name if Possible) Ie RN Robinson Patency of airway and IV fluidsPatency of airway and IV fluids
CHRONOLOGICALCHRONOLOGICAL
ldquoldquoWrite like your brain thinks itrdquoWrite like your brain thinks itrdquo
Dispatched non-emergent to University Hospitals Dispatched non-emergent to University Hospitals Emergency Educations center for a transport to Emergency Educations center for a transport to UW ER Arrived on floor and met by staff who UW ER Arrived on floor and met by staff who advised us that the patient was suffering from advised us that the patient was suffering from severe PES (Paramedic Education Syndrome) severe PES (Paramedic Education Syndrome) Patient is Mr D a 48 yo male with hx of PES and Patient is Mr D a 48 yo male with hx of PES and CHF who presented with chest pain and CHF who presented with chest pain and dyspneahellipdyspneahellip
Errors and FalsificationsErrors and Falsifications
Avoid ErrorsAvoid Errors Admit when you made a mistakeAdmit when you made a mistake
Revise if necessaryRevise if necessary Note date and time of revisionNote date and time of revision Keep original documentKeep original document Include purpose of the revisionInclude purpose of the revision Only the original author can make the Only the original author can make the
correctioncorrection
Errors and FalsificationsErrors and Falsifications
Always be honest and through in your Always be honest and through in your documentationdocumentation
CorrectionsCorrections Add a supplement on electronic reportsAdd a supplement on electronic reports One line across the error initial the One line across the error initial the
mistake and make the corrections on mistake and make the corrections on written reportswritten reports
Complete reports as soon as possible Complete reports as soon as possible Lost reports have HUGE legal implicationsLost reports have HUGE legal implications Dont keep copies of your reportsDont keep copies of your reports
HIPPAHIPPA
What Happens on What Happens on the Ambulance the Ambulance stays on the stays on the ambulance ambulance
Health Health InsuranceInsurance PortabilityPortability PrivacyPrivacy AccountabilityAccountability
HIPPAHIPPA
Protects the security and privacy of Protects the security and privacy of all medical records and other health all medical records and other health information used or shared in any information used or shared in any formform
Protects patients rights by giving Protects patients rights by giving access to health information and access to health information and control over how it is usedcontrol over how it is used
PHIPHI Protected Heath InformationProtected Heath Information
Information that relates toInformation that relates to The health of an individualThe health of an individual Health care provided to that individualHealth care provided to that individual Payment of heath care providedPayment of heath care provided
What can be sharedWhat can be shared
Health Insurance Company my need Health Insurance Company my need information to process a claiminformation to process a claim
Caregivers involved with direct care Caregivers involved with direct care Quality Assurance when necessaryQuality Assurance when necessary
Special ConsiderationsSpecial Considerations
Exposure and InjuryExposure and Injury Mass CasualtyMass Casualty Interfacility TransportsInterfacility Transports RefusalsRefusals
Mass Casualty EventsMass Casualty Events
Documentation may have to be Documentation may have to be postponedpostponed
Follow Local Policy and ProcedureFollow Local Policy and Procedure Comprehensive run report must be Comprehensive run report must be
completed for each patient when completed for each patient when time permitstime permits
Refusal of CareRefusal of Care
Potential for LiabilityPotential for Liability Good DocumentationGood Documentation Make it clearMake it clear
Refusal of CareRefusal of Care
The litigation rate for EMS has been steadily increasing
1048657 According to one study patients evaluatedby paramedics but not transported to thehospital account for 50 to 90 of EMSlawsuitsrdquo
1048657 Documentation is your best defenserdquo
DocumentationDocumentation
Physical FindingsPhysical Findings The advice you give the patient about The advice you give the patient about
being transported and the associated being transported and the associated risks for not being transportedrisks for not being transported
Clinical indications that patient is Clinical indications that patient is competent to make a rational decisioncompetent to make a rational decision
Signatures of the patient and witnessSignatures of the patient and witness Full narrativeFull narrative Advise to call 911 if condition changesAdvise to call 911 if condition changes
Do not at any time attempt to talk the patient out of going to the hospital
If you feel strongly that the patient should be seen make every attempt to convince them they should be seen
Donrsquot say lsquo I agree you donrsquot need to gordquo even if you agree
What not to sayWhat not to say
A patient suffers a diabetic emergency She is treated by the local EMS crew with an A patient suffers a diabetic emergency She is treated by the local EMS crew with an IV an ampule of D50 and transported to the closet hospital despite family members IV an ampule of D50 and transported to the closet hospital despite family members telling you that the patient does not go theretelling you that the patient does not go there
Transport is uneventful and care is turned over to the ED Nurse with a quick verbal Transport is uneventful and care is turned over to the ED Nurse with a quick verbal reportreport
An hour later a private ambulance is called to transport the patient to her desired An hour later a private ambulance is called to transport the patient to her desired hospital for definitive care They notice the IV has infiltrated and D50 got into her hospital for definitive care They notice the IV has infiltrated and D50 got into her surrounding tissuessurrounding tissues
The patient suffers significant tissue damage which requires a fasciotomy to The patient suffers significant tissue damage which requires a fasciotomy to decompress her hand and forearm She has permanent nerve damage and requires decompress her hand and forearm She has permanent nerve damage and requires skin graftingskin grafting
Initial Transport Agency-CFDInitial Transport Agency-CFD
First Receiving Hospital-St Anthony HospitalFirst Receiving Hospital-St Anthony Hospital
Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998
Lets Finish upLets Finish up
Be ProfessionalBe Professional AccurateAccurate ConsistentConsistent ThroughThrough ClearClear BriefBrief Paint the PicturePaint the Picture CollaborativeCollaborative
Legible spelling Legible spelling correctcorrect
Tell the TruthTell the Truth Donrsquot duplicate infoDonrsquot duplicate info Follow ProtocolsFollow Protocols Plain LanguagePlain Language Relevant InformationRelevant Information ldquoldquoThe JURYrdquoThe JURYrdquo Have your partner Have your partner
reviewreview
(A) Assessment(A) Assessment
Include both negative and positive findings Responses the patient has to your
assessment such as the presence or lack of pain andor the presence or lack of sensation
Diagnostic Testing ECG Pulse Oximetry Capnography Blood Glucose Monitoring
(R) Rx-Treatment(R) Rx-Treatment
Document your treatmentDocument your treatment Responses from the Patient to RxResponses from the Patient to Rx Changes in Patients conditionChanges in Patients condition
Example Example ldquoPain decreased to 510 from ldquoPain decreased to 510 from 710 after NTG administered710 after NTG administered
(T) Transport(T) Transport
Where did you goWhere did you go Change in condition during Change in condition during
transporttransport Alteration from ProtocolAlteration from Protocol Who did you turn care over to Who did you turn care over to
(Name if Possible) Ie RN Robinson(Name if Possible) Ie RN Robinson Patency of airway and IV fluidsPatency of airway and IV fluids
CHRONOLOGICALCHRONOLOGICAL
ldquoldquoWrite like your brain thinks itrdquoWrite like your brain thinks itrdquo
Dispatched non-emergent to University Hospitals Dispatched non-emergent to University Hospitals Emergency Educations center for a transport to Emergency Educations center for a transport to UW ER Arrived on floor and met by staff who UW ER Arrived on floor and met by staff who advised us that the patient was suffering from advised us that the patient was suffering from severe PES (Paramedic Education Syndrome) severe PES (Paramedic Education Syndrome) Patient is Mr D a 48 yo male with hx of PES and Patient is Mr D a 48 yo male with hx of PES and CHF who presented with chest pain and CHF who presented with chest pain and dyspneahellipdyspneahellip
Errors and FalsificationsErrors and Falsifications
Avoid ErrorsAvoid Errors Admit when you made a mistakeAdmit when you made a mistake
Revise if necessaryRevise if necessary Note date and time of revisionNote date and time of revision Keep original documentKeep original document Include purpose of the revisionInclude purpose of the revision Only the original author can make the Only the original author can make the
correctioncorrection
Errors and FalsificationsErrors and Falsifications
Always be honest and through in your Always be honest and through in your documentationdocumentation
CorrectionsCorrections Add a supplement on electronic reportsAdd a supplement on electronic reports One line across the error initial the One line across the error initial the
mistake and make the corrections on mistake and make the corrections on written reportswritten reports
Complete reports as soon as possible Complete reports as soon as possible Lost reports have HUGE legal implicationsLost reports have HUGE legal implications Dont keep copies of your reportsDont keep copies of your reports
HIPPAHIPPA
What Happens on What Happens on the Ambulance the Ambulance stays on the stays on the ambulance ambulance
Health Health InsuranceInsurance PortabilityPortability PrivacyPrivacy AccountabilityAccountability
HIPPAHIPPA
Protects the security and privacy of Protects the security and privacy of all medical records and other health all medical records and other health information used or shared in any information used or shared in any formform
Protects patients rights by giving Protects patients rights by giving access to health information and access to health information and control over how it is usedcontrol over how it is used
PHIPHI Protected Heath InformationProtected Heath Information
Information that relates toInformation that relates to The health of an individualThe health of an individual Health care provided to that individualHealth care provided to that individual Payment of heath care providedPayment of heath care provided
What can be sharedWhat can be shared
Health Insurance Company my need Health Insurance Company my need information to process a claiminformation to process a claim
Caregivers involved with direct care Caregivers involved with direct care Quality Assurance when necessaryQuality Assurance when necessary
Special ConsiderationsSpecial Considerations
Exposure and InjuryExposure and Injury Mass CasualtyMass Casualty Interfacility TransportsInterfacility Transports RefusalsRefusals
Mass Casualty EventsMass Casualty Events
Documentation may have to be Documentation may have to be postponedpostponed
Follow Local Policy and ProcedureFollow Local Policy and Procedure Comprehensive run report must be Comprehensive run report must be
completed for each patient when completed for each patient when time permitstime permits
Refusal of CareRefusal of Care
Potential for LiabilityPotential for Liability Good DocumentationGood Documentation Make it clearMake it clear
Refusal of CareRefusal of Care
The litigation rate for EMS has been steadily increasing
1048657 According to one study patients evaluatedby paramedics but not transported to thehospital account for 50 to 90 of EMSlawsuitsrdquo
1048657 Documentation is your best defenserdquo
DocumentationDocumentation
Physical FindingsPhysical Findings The advice you give the patient about The advice you give the patient about
being transported and the associated being transported and the associated risks for not being transportedrisks for not being transported
Clinical indications that patient is Clinical indications that patient is competent to make a rational decisioncompetent to make a rational decision
Signatures of the patient and witnessSignatures of the patient and witness Full narrativeFull narrative Advise to call 911 if condition changesAdvise to call 911 if condition changes
Do not at any time attempt to talk the patient out of going to the hospital
If you feel strongly that the patient should be seen make every attempt to convince them they should be seen
Donrsquot say lsquo I agree you donrsquot need to gordquo even if you agree
What not to sayWhat not to say
A patient suffers a diabetic emergency She is treated by the local EMS crew with an A patient suffers a diabetic emergency She is treated by the local EMS crew with an IV an ampule of D50 and transported to the closet hospital despite family members IV an ampule of D50 and transported to the closet hospital despite family members telling you that the patient does not go theretelling you that the patient does not go there
Transport is uneventful and care is turned over to the ED Nurse with a quick verbal Transport is uneventful and care is turned over to the ED Nurse with a quick verbal reportreport
An hour later a private ambulance is called to transport the patient to her desired An hour later a private ambulance is called to transport the patient to her desired hospital for definitive care They notice the IV has infiltrated and D50 got into her hospital for definitive care They notice the IV has infiltrated and D50 got into her surrounding tissuessurrounding tissues
The patient suffers significant tissue damage which requires a fasciotomy to The patient suffers significant tissue damage which requires a fasciotomy to decompress her hand and forearm She has permanent nerve damage and requires decompress her hand and forearm She has permanent nerve damage and requires skin graftingskin grafting
Initial Transport Agency-CFDInitial Transport Agency-CFD
First Receiving Hospital-St Anthony HospitalFirst Receiving Hospital-St Anthony Hospital
Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998
Lets Finish upLets Finish up
Be ProfessionalBe Professional AccurateAccurate ConsistentConsistent ThroughThrough ClearClear BriefBrief Paint the PicturePaint the Picture CollaborativeCollaborative
Legible spelling Legible spelling correctcorrect
Tell the TruthTell the Truth Donrsquot duplicate infoDonrsquot duplicate info Follow ProtocolsFollow Protocols Plain LanguagePlain Language Relevant InformationRelevant Information ldquoldquoThe JURYrdquoThe JURYrdquo Have your partner Have your partner
reviewreview
(R) Rx-Treatment(R) Rx-Treatment
Document your treatmentDocument your treatment Responses from the Patient to RxResponses from the Patient to Rx Changes in Patients conditionChanges in Patients condition
Example Example ldquoPain decreased to 510 from ldquoPain decreased to 510 from 710 after NTG administered710 after NTG administered
(T) Transport(T) Transport
Where did you goWhere did you go Change in condition during Change in condition during
transporttransport Alteration from ProtocolAlteration from Protocol Who did you turn care over to Who did you turn care over to
(Name if Possible) Ie RN Robinson(Name if Possible) Ie RN Robinson Patency of airway and IV fluidsPatency of airway and IV fluids
CHRONOLOGICALCHRONOLOGICAL
ldquoldquoWrite like your brain thinks itrdquoWrite like your brain thinks itrdquo
Dispatched non-emergent to University Hospitals Dispatched non-emergent to University Hospitals Emergency Educations center for a transport to Emergency Educations center for a transport to UW ER Arrived on floor and met by staff who UW ER Arrived on floor and met by staff who advised us that the patient was suffering from advised us that the patient was suffering from severe PES (Paramedic Education Syndrome) severe PES (Paramedic Education Syndrome) Patient is Mr D a 48 yo male with hx of PES and Patient is Mr D a 48 yo male with hx of PES and CHF who presented with chest pain and CHF who presented with chest pain and dyspneahellipdyspneahellip
Errors and FalsificationsErrors and Falsifications
Avoid ErrorsAvoid Errors Admit when you made a mistakeAdmit when you made a mistake
Revise if necessaryRevise if necessary Note date and time of revisionNote date and time of revision Keep original documentKeep original document Include purpose of the revisionInclude purpose of the revision Only the original author can make the Only the original author can make the
correctioncorrection
Errors and FalsificationsErrors and Falsifications
Always be honest and through in your Always be honest and through in your documentationdocumentation
CorrectionsCorrections Add a supplement on electronic reportsAdd a supplement on electronic reports One line across the error initial the One line across the error initial the
mistake and make the corrections on mistake and make the corrections on written reportswritten reports
Complete reports as soon as possible Complete reports as soon as possible Lost reports have HUGE legal implicationsLost reports have HUGE legal implications Dont keep copies of your reportsDont keep copies of your reports
HIPPAHIPPA
What Happens on What Happens on the Ambulance the Ambulance stays on the stays on the ambulance ambulance
Health Health InsuranceInsurance PortabilityPortability PrivacyPrivacy AccountabilityAccountability
HIPPAHIPPA
Protects the security and privacy of Protects the security and privacy of all medical records and other health all medical records and other health information used or shared in any information used or shared in any formform
Protects patients rights by giving Protects patients rights by giving access to health information and access to health information and control over how it is usedcontrol over how it is used
PHIPHI Protected Heath InformationProtected Heath Information
Information that relates toInformation that relates to The health of an individualThe health of an individual Health care provided to that individualHealth care provided to that individual Payment of heath care providedPayment of heath care provided
What can be sharedWhat can be shared
Health Insurance Company my need Health Insurance Company my need information to process a claiminformation to process a claim
Caregivers involved with direct care Caregivers involved with direct care Quality Assurance when necessaryQuality Assurance when necessary
Special ConsiderationsSpecial Considerations
Exposure and InjuryExposure and Injury Mass CasualtyMass Casualty Interfacility TransportsInterfacility Transports RefusalsRefusals
Mass Casualty EventsMass Casualty Events
Documentation may have to be Documentation may have to be postponedpostponed
Follow Local Policy and ProcedureFollow Local Policy and Procedure Comprehensive run report must be Comprehensive run report must be
completed for each patient when completed for each patient when time permitstime permits
Refusal of CareRefusal of Care
Potential for LiabilityPotential for Liability Good DocumentationGood Documentation Make it clearMake it clear
Refusal of CareRefusal of Care
The litigation rate for EMS has been steadily increasing
1048657 According to one study patients evaluatedby paramedics but not transported to thehospital account for 50 to 90 of EMSlawsuitsrdquo
1048657 Documentation is your best defenserdquo
DocumentationDocumentation
Physical FindingsPhysical Findings The advice you give the patient about The advice you give the patient about
being transported and the associated being transported and the associated risks for not being transportedrisks for not being transported
Clinical indications that patient is Clinical indications that patient is competent to make a rational decisioncompetent to make a rational decision
Signatures of the patient and witnessSignatures of the patient and witness Full narrativeFull narrative Advise to call 911 if condition changesAdvise to call 911 if condition changes
Do not at any time attempt to talk the patient out of going to the hospital
If you feel strongly that the patient should be seen make every attempt to convince them they should be seen
Donrsquot say lsquo I agree you donrsquot need to gordquo even if you agree
What not to sayWhat not to say
A patient suffers a diabetic emergency She is treated by the local EMS crew with an A patient suffers a diabetic emergency She is treated by the local EMS crew with an IV an ampule of D50 and transported to the closet hospital despite family members IV an ampule of D50 and transported to the closet hospital despite family members telling you that the patient does not go theretelling you that the patient does not go there
Transport is uneventful and care is turned over to the ED Nurse with a quick verbal Transport is uneventful and care is turned over to the ED Nurse with a quick verbal reportreport
An hour later a private ambulance is called to transport the patient to her desired An hour later a private ambulance is called to transport the patient to her desired hospital for definitive care They notice the IV has infiltrated and D50 got into her hospital for definitive care They notice the IV has infiltrated and D50 got into her surrounding tissuessurrounding tissues
The patient suffers significant tissue damage which requires a fasciotomy to The patient suffers significant tissue damage which requires a fasciotomy to decompress her hand and forearm She has permanent nerve damage and requires decompress her hand and forearm She has permanent nerve damage and requires skin graftingskin grafting
Initial Transport Agency-CFDInitial Transport Agency-CFD
First Receiving Hospital-St Anthony HospitalFirst Receiving Hospital-St Anthony Hospital
Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998
Lets Finish upLets Finish up
Be ProfessionalBe Professional AccurateAccurate ConsistentConsistent ThroughThrough ClearClear BriefBrief Paint the PicturePaint the Picture CollaborativeCollaborative
Legible spelling Legible spelling correctcorrect
Tell the TruthTell the Truth Donrsquot duplicate infoDonrsquot duplicate info Follow ProtocolsFollow Protocols Plain LanguagePlain Language Relevant InformationRelevant Information ldquoldquoThe JURYrdquoThe JURYrdquo Have your partner Have your partner
reviewreview
(T) Transport(T) Transport
Where did you goWhere did you go Change in condition during Change in condition during
transporttransport Alteration from ProtocolAlteration from Protocol Who did you turn care over to Who did you turn care over to
(Name if Possible) Ie RN Robinson(Name if Possible) Ie RN Robinson Patency of airway and IV fluidsPatency of airway and IV fluids
CHRONOLOGICALCHRONOLOGICAL
ldquoldquoWrite like your brain thinks itrdquoWrite like your brain thinks itrdquo
Dispatched non-emergent to University Hospitals Dispatched non-emergent to University Hospitals Emergency Educations center for a transport to Emergency Educations center for a transport to UW ER Arrived on floor and met by staff who UW ER Arrived on floor and met by staff who advised us that the patient was suffering from advised us that the patient was suffering from severe PES (Paramedic Education Syndrome) severe PES (Paramedic Education Syndrome) Patient is Mr D a 48 yo male with hx of PES and Patient is Mr D a 48 yo male with hx of PES and CHF who presented with chest pain and CHF who presented with chest pain and dyspneahellipdyspneahellip
Errors and FalsificationsErrors and Falsifications
Avoid ErrorsAvoid Errors Admit when you made a mistakeAdmit when you made a mistake
Revise if necessaryRevise if necessary Note date and time of revisionNote date and time of revision Keep original documentKeep original document Include purpose of the revisionInclude purpose of the revision Only the original author can make the Only the original author can make the
correctioncorrection
Errors and FalsificationsErrors and Falsifications
Always be honest and through in your Always be honest and through in your documentationdocumentation
CorrectionsCorrections Add a supplement on electronic reportsAdd a supplement on electronic reports One line across the error initial the One line across the error initial the
mistake and make the corrections on mistake and make the corrections on written reportswritten reports
Complete reports as soon as possible Complete reports as soon as possible Lost reports have HUGE legal implicationsLost reports have HUGE legal implications Dont keep copies of your reportsDont keep copies of your reports
HIPPAHIPPA
What Happens on What Happens on the Ambulance the Ambulance stays on the stays on the ambulance ambulance
Health Health InsuranceInsurance PortabilityPortability PrivacyPrivacy AccountabilityAccountability
HIPPAHIPPA
Protects the security and privacy of Protects the security and privacy of all medical records and other health all medical records and other health information used or shared in any information used or shared in any formform
Protects patients rights by giving Protects patients rights by giving access to health information and access to health information and control over how it is usedcontrol over how it is used
PHIPHI Protected Heath InformationProtected Heath Information
Information that relates toInformation that relates to The health of an individualThe health of an individual Health care provided to that individualHealth care provided to that individual Payment of heath care providedPayment of heath care provided
What can be sharedWhat can be shared
Health Insurance Company my need Health Insurance Company my need information to process a claiminformation to process a claim
Caregivers involved with direct care Caregivers involved with direct care Quality Assurance when necessaryQuality Assurance when necessary
Special ConsiderationsSpecial Considerations
Exposure and InjuryExposure and Injury Mass CasualtyMass Casualty Interfacility TransportsInterfacility Transports RefusalsRefusals
Mass Casualty EventsMass Casualty Events
Documentation may have to be Documentation may have to be postponedpostponed
Follow Local Policy and ProcedureFollow Local Policy and Procedure Comprehensive run report must be Comprehensive run report must be
completed for each patient when completed for each patient when time permitstime permits
Refusal of CareRefusal of Care
Potential for LiabilityPotential for Liability Good DocumentationGood Documentation Make it clearMake it clear
Refusal of CareRefusal of Care
The litigation rate for EMS has been steadily increasing
1048657 According to one study patients evaluatedby paramedics but not transported to thehospital account for 50 to 90 of EMSlawsuitsrdquo
1048657 Documentation is your best defenserdquo
DocumentationDocumentation
Physical FindingsPhysical Findings The advice you give the patient about The advice you give the patient about
being transported and the associated being transported and the associated risks for not being transportedrisks for not being transported
Clinical indications that patient is Clinical indications that patient is competent to make a rational decisioncompetent to make a rational decision
Signatures of the patient and witnessSignatures of the patient and witness Full narrativeFull narrative Advise to call 911 if condition changesAdvise to call 911 if condition changes
Do not at any time attempt to talk the patient out of going to the hospital
If you feel strongly that the patient should be seen make every attempt to convince them they should be seen
Donrsquot say lsquo I agree you donrsquot need to gordquo even if you agree
What not to sayWhat not to say
A patient suffers a diabetic emergency She is treated by the local EMS crew with an A patient suffers a diabetic emergency She is treated by the local EMS crew with an IV an ampule of D50 and transported to the closet hospital despite family members IV an ampule of D50 and transported to the closet hospital despite family members telling you that the patient does not go theretelling you that the patient does not go there
Transport is uneventful and care is turned over to the ED Nurse with a quick verbal Transport is uneventful and care is turned over to the ED Nurse with a quick verbal reportreport
An hour later a private ambulance is called to transport the patient to her desired An hour later a private ambulance is called to transport the patient to her desired hospital for definitive care They notice the IV has infiltrated and D50 got into her hospital for definitive care They notice the IV has infiltrated and D50 got into her surrounding tissuessurrounding tissues
The patient suffers significant tissue damage which requires a fasciotomy to The patient suffers significant tissue damage which requires a fasciotomy to decompress her hand and forearm She has permanent nerve damage and requires decompress her hand and forearm She has permanent nerve damage and requires skin graftingskin grafting
Initial Transport Agency-CFDInitial Transport Agency-CFD
First Receiving Hospital-St Anthony HospitalFirst Receiving Hospital-St Anthony Hospital
Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998
Lets Finish upLets Finish up
Be ProfessionalBe Professional AccurateAccurate ConsistentConsistent ThroughThrough ClearClear BriefBrief Paint the PicturePaint the Picture CollaborativeCollaborative
Legible spelling Legible spelling correctcorrect
Tell the TruthTell the Truth Donrsquot duplicate infoDonrsquot duplicate info Follow ProtocolsFollow Protocols Plain LanguagePlain Language Relevant InformationRelevant Information ldquoldquoThe JURYrdquoThe JURYrdquo Have your partner Have your partner
reviewreview
CHRONOLOGICALCHRONOLOGICAL
ldquoldquoWrite like your brain thinks itrdquoWrite like your brain thinks itrdquo
Dispatched non-emergent to University Hospitals Dispatched non-emergent to University Hospitals Emergency Educations center for a transport to Emergency Educations center for a transport to UW ER Arrived on floor and met by staff who UW ER Arrived on floor and met by staff who advised us that the patient was suffering from advised us that the patient was suffering from severe PES (Paramedic Education Syndrome) severe PES (Paramedic Education Syndrome) Patient is Mr D a 48 yo male with hx of PES and Patient is Mr D a 48 yo male with hx of PES and CHF who presented with chest pain and CHF who presented with chest pain and dyspneahellipdyspneahellip
Errors and FalsificationsErrors and Falsifications
Avoid ErrorsAvoid Errors Admit when you made a mistakeAdmit when you made a mistake
Revise if necessaryRevise if necessary Note date and time of revisionNote date and time of revision Keep original documentKeep original document Include purpose of the revisionInclude purpose of the revision Only the original author can make the Only the original author can make the
correctioncorrection
Errors and FalsificationsErrors and Falsifications
Always be honest and through in your Always be honest and through in your documentationdocumentation
CorrectionsCorrections Add a supplement on electronic reportsAdd a supplement on electronic reports One line across the error initial the One line across the error initial the
mistake and make the corrections on mistake and make the corrections on written reportswritten reports
Complete reports as soon as possible Complete reports as soon as possible Lost reports have HUGE legal implicationsLost reports have HUGE legal implications Dont keep copies of your reportsDont keep copies of your reports
HIPPAHIPPA
What Happens on What Happens on the Ambulance the Ambulance stays on the stays on the ambulance ambulance
Health Health InsuranceInsurance PortabilityPortability PrivacyPrivacy AccountabilityAccountability
HIPPAHIPPA
Protects the security and privacy of Protects the security and privacy of all medical records and other health all medical records and other health information used or shared in any information used or shared in any formform
Protects patients rights by giving Protects patients rights by giving access to health information and access to health information and control over how it is usedcontrol over how it is used
PHIPHI Protected Heath InformationProtected Heath Information
Information that relates toInformation that relates to The health of an individualThe health of an individual Health care provided to that individualHealth care provided to that individual Payment of heath care providedPayment of heath care provided
What can be sharedWhat can be shared
Health Insurance Company my need Health Insurance Company my need information to process a claiminformation to process a claim
Caregivers involved with direct care Caregivers involved with direct care Quality Assurance when necessaryQuality Assurance when necessary
Special ConsiderationsSpecial Considerations
Exposure and InjuryExposure and Injury Mass CasualtyMass Casualty Interfacility TransportsInterfacility Transports RefusalsRefusals
Mass Casualty EventsMass Casualty Events
Documentation may have to be Documentation may have to be postponedpostponed
Follow Local Policy and ProcedureFollow Local Policy and Procedure Comprehensive run report must be Comprehensive run report must be
completed for each patient when completed for each patient when time permitstime permits
Refusal of CareRefusal of Care
Potential for LiabilityPotential for Liability Good DocumentationGood Documentation Make it clearMake it clear
Refusal of CareRefusal of Care
The litigation rate for EMS has been steadily increasing
1048657 According to one study patients evaluatedby paramedics but not transported to thehospital account for 50 to 90 of EMSlawsuitsrdquo
1048657 Documentation is your best defenserdquo
DocumentationDocumentation
Physical FindingsPhysical Findings The advice you give the patient about The advice you give the patient about
being transported and the associated being transported and the associated risks for not being transportedrisks for not being transported
Clinical indications that patient is Clinical indications that patient is competent to make a rational decisioncompetent to make a rational decision
Signatures of the patient and witnessSignatures of the patient and witness Full narrativeFull narrative Advise to call 911 if condition changesAdvise to call 911 if condition changes
Do not at any time attempt to talk the patient out of going to the hospital
If you feel strongly that the patient should be seen make every attempt to convince them they should be seen
Donrsquot say lsquo I agree you donrsquot need to gordquo even if you agree
What not to sayWhat not to say
A patient suffers a diabetic emergency She is treated by the local EMS crew with an A patient suffers a diabetic emergency She is treated by the local EMS crew with an IV an ampule of D50 and transported to the closet hospital despite family members IV an ampule of D50 and transported to the closet hospital despite family members telling you that the patient does not go theretelling you that the patient does not go there
Transport is uneventful and care is turned over to the ED Nurse with a quick verbal Transport is uneventful and care is turned over to the ED Nurse with a quick verbal reportreport
An hour later a private ambulance is called to transport the patient to her desired An hour later a private ambulance is called to transport the patient to her desired hospital for definitive care They notice the IV has infiltrated and D50 got into her hospital for definitive care They notice the IV has infiltrated and D50 got into her surrounding tissuessurrounding tissues
The patient suffers significant tissue damage which requires a fasciotomy to The patient suffers significant tissue damage which requires a fasciotomy to decompress her hand and forearm She has permanent nerve damage and requires decompress her hand and forearm She has permanent nerve damage and requires skin graftingskin grafting
Initial Transport Agency-CFDInitial Transport Agency-CFD
First Receiving Hospital-St Anthony HospitalFirst Receiving Hospital-St Anthony Hospital
Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998
Lets Finish upLets Finish up
Be ProfessionalBe Professional AccurateAccurate ConsistentConsistent ThroughThrough ClearClear BriefBrief Paint the PicturePaint the Picture CollaborativeCollaborative
Legible spelling Legible spelling correctcorrect
Tell the TruthTell the Truth Donrsquot duplicate infoDonrsquot duplicate info Follow ProtocolsFollow Protocols Plain LanguagePlain Language Relevant InformationRelevant Information ldquoldquoThe JURYrdquoThe JURYrdquo Have your partner Have your partner
reviewreview
Errors and FalsificationsErrors and Falsifications
Avoid ErrorsAvoid Errors Admit when you made a mistakeAdmit when you made a mistake
Revise if necessaryRevise if necessary Note date and time of revisionNote date and time of revision Keep original documentKeep original document Include purpose of the revisionInclude purpose of the revision Only the original author can make the Only the original author can make the
correctioncorrection
Errors and FalsificationsErrors and Falsifications
Always be honest and through in your Always be honest and through in your documentationdocumentation
CorrectionsCorrections Add a supplement on electronic reportsAdd a supplement on electronic reports One line across the error initial the One line across the error initial the
mistake and make the corrections on mistake and make the corrections on written reportswritten reports
Complete reports as soon as possible Complete reports as soon as possible Lost reports have HUGE legal implicationsLost reports have HUGE legal implications Dont keep copies of your reportsDont keep copies of your reports
HIPPAHIPPA
What Happens on What Happens on the Ambulance the Ambulance stays on the stays on the ambulance ambulance
Health Health InsuranceInsurance PortabilityPortability PrivacyPrivacy AccountabilityAccountability
HIPPAHIPPA
Protects the security and privacy of Protects the security and privacy of all medical records and other health all medical records and other health information used or shared in any information used or shared in any formform
Protects patients rights by giving Protects patients rights by giving access to health information and access to health information and control over how it is usedcontrol over how it is used
PHIPHI Protected Heath InformationProtected Heath Information
Information that relates toInformation that relates to The health of an individualThe health of an individual Health care provided to that individualHealth care provided to that individual Payment of heath care providedPayment of heath care provided
What can be sharedWhat can be shared
Health Insurance Company my need Health Insurance Company my need information to process a claiminformation to process a claim
Caregivers involved with direct care Caregivers involved with direct care Quality Assurance when necessaryQuality Assurance when necessary
Special ConsiderationsSpecial Considerations
Exposure and InjuryExposure and Injury Mass CasualtyMass Casualty Interfacility TransportsInterfacility Transports RefusalsRefusals
Mass Casualty EventsMass Casualty Events
Documentation may have to be Documentation may have to be postponedpostponed
Follow Local Policy and ProcedureFollow Local Policy and Procedure Comprehensive run report must be Comprehensive run report must be
completed for each patient when completed for each patient when time permitstime permits
Refusal of CareRefusal of Care
Potential for LiabilityPotential for Liability Good DocumentationGood Documentation Make it clearMake it clear
Refusal of CareRefusal of Care
The litigation rate for EMS has been steadily increasing
1048657 According to one study patients evaluatedby paramedics but not transported to thehospital account for 50 to 90 of EMSlawsuitsrdquo
1048657 Documentation is your best defenserdquo
DocumentationDocumentation
Physical FindingsPhysical Findings The advice you give the patient about The advice you give the patient about
being transported and the associated being transported and the associated risks for not being transportedrisks for not being transported
Clinical indications that patient is Clinical indications that patient is competent to make a rational decisioncompetent to make a rational decision
Signatures of the patient and witnessSignatures of the patient and witness Full narrativeFull narrative Advise to call 911 if condition changesAdvise to call 911 if condition changes
Do not at any time attempt to talk the patient out of going to the hospital
If you feel strongly that the patient should be seen make every attempt to convince them they should be seen
Donrsquot say lsquo I agree you donrsquot need to gordquo even if you agree
What not to sayWhat not to say
A patient suffers a diabetic emergency She is treated by the local EMS crew with an A patient suffers a diabetic emergency She is treated by the local EMS crew with an IV an ampule of D50 and transported to the closet hospital despite family members IV an ampule of D50 and transported to the closet hospital despite family members telling you that the patient does not go theretelling you that the patient does not go there
Transport is uneventful and care is turned over to the ED Nurse with a quick verbal Transport is uneventful and care is turned over to the ED Nurse with a quick verbal reportreport
An hour later a private ambulance is called to transport the patient to her desired An hour later a private ambulance is called to transport the patient to her desired hospital for definitive care They notice the IV has infiltrated and D50 got into her hospital for definitive care They notice the IV has infiltrated and D50 got into her surrounding tissuessurrounding tissues
The patient suffers significant tissue damage which requires a fasciotomy to The patient suffers significant tissue damage which requires a fasciotomy to decompress her hand and forearm She has permanent nerve damage and requires decompress her hand and forearm She has permanent nerve damage and requires skin graftingskin grafting
Initial Transport Agency-CFDInitial Transport Agency-CFD
First Receiving Hospital-St Anthony HospitalFirst Receiving Hospital-St Anthony Hospital
Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998
Lets Finish upLets Finish up
Be ProfessionalBe Professional AccurateAccurate ConsistentConsistent ThroughThrough ClearClear BriefBrief Paint the PicturePaint the Picture CollaborativeCollaborative
Legible spelling Legible spelling correctcorrect
Tell the TruthTell the Truth Donrsquot duplicate infoDonrsquot duplicate info Follow ProtocolsFollow Protocols Plain LanguagePlain Language Relevant InformationRelevant Information ldquoldquoThe JURYrdquoThe JURYrdquo Have your partner Have your partner
reviewreview
Errors and FalsificationsErrors and Falsifications
Always be honest and through in your Always be honest and through in your documentationdocumentation
CorrectionsCorrections Add a supplement on electronic reportsAdd a supplement on electronic reports One line across the error initial the One line across the error initial the
mistake and make the corrections on mistake and make the corrections on written reportswritten reports
Complete reports as soon as possible Complete reports as soon as possible Lost reports have HUGE legal implicationsLost reports have HUGE legal implications Dont keep copies of your reportsDont keep copies of your reports
HIPPAHIPPA
What Happens on What Happens on the Ambulance the Ambulance stays on the stays on the ambulance ambulance
Health Health InsuranceInsurance PortabilityPortability PrivacyPrivacy AccountabilityAccountability
HIPPAHIPPA
Protects the security and privacy of Protects the security and privacy of all medical records and other health all medical records and other health information used or shared in any information used or shared in any formform
Protects patients rights by giving Protects patients rights by giving access to health information and access to health information and control over how it is usedcontrol over how it is used
PHIPHI Protected Heath InformationProtected Heath Information
Information that relates toInformation that relates to The health of an individualThe health of an individual Health care provided to that individualHealth care provided to that individual Payment of heath care providedPayment of heath care provided
What can be sharedWhat can be shared
Health Insurance Company my need Health Insurance Company my need information to process a claiminformation to process a claim
Caregivers involved with direct care Caregivers involved with direct care Quality Assurance when necessaryQuality Assurance when necessary
Special ConsiderationsSpecial Considerations
Exposure and InjuryExposure and Injury Mass CasualtyMass Casualty Interfacility TransportsInterfacility Transports RefusalsRefusals
Mass Casualty EventsMass Casualty Events
Documentation may have to be Documentation may have to be postponedpostponed
Follow Local Policy and ProcedureFollow Local Policy and Procedure Comprehensive run report must be Comprehensive run report must be
completed for each patient when completed for each patient when time permitstime permits
Refusal of CareRefusal of Care
Potential for LiabilityPotential for Liability Good DocumentationGood Documentation Make it clearMake it clear
Refusal of CareRefusal of Care
The litigation rate for EMS has been steadily increasing
1048657 According to one study patients evaluatedby paramedics but not transported to thehospital account for 50 to 90 of EMSlawsuitsrdquo
1048657 Documentation is your best defenserdquo
DocumentationDocumentation
Physical FindingsPhysical Findings The advice you give the patient about The advice you give the patient about
being transported and the associated being transported and the associated risks for not being transportedrisks for not being transported
Clinical indications that patient is Clinical indications that patient is competent to make a rational decisioncompetent to make a rational decision
Signatures of the patient and witnessSignatures of the patient and witness Full narrativeFull narrative Advise to call 911 if condition changesAdvise to call 911 if condition changes
Do not at any time attempt to talk the patient out of going to the hospital
If you feel strongly that the patient should be seen make every attempt to convince them they should be seen
Donrsquot say lsquo I agree you donrsquot need to gordquo even if you agree
What not to sayWhat not to say
A patient suffers a diabetic emergency She is treated by the local EMS crew with an A patient suffers a diabetic emergency She is treated by the local EMS crew with an IV an ampule of D50 and transported to the closet hospital despite family members IV an ampule of D50 and transported to the closet hospital despite family members telling you that the patient does not go theretelling you that the patient does not go there
Transport is uneventful and care is turned over to the ED Nurse with a quick verbal Transport is uneventful and care is turned over to the ED Nurse with a quick verbal reportreport
An hour later a private ambulance is called to transport the patient to her desired An hour later a private ambulance is called to transport the patient to her desired hospital for definitive care They notice the IV has infiltrated and D50 got into her hospital for definitive care They notice the IV has infiltrated and D50 got into her surrounding tissuessurrounding tissues
The patient suffers significant tissue damage which requires a fasciotomy to The patient suffers significant tissue damage which requires a fasciotomy to decompress her hand and forearm She has permanent nerve damage and requires decompress her hand and forearm She has permanent nerve damage and requires skin graftingskin grafting
Initial Transport Agency-CFDInitial Transport Agency-CFD
First Receiving Hospital-St Anthony HospitalFirst Receiving Hospital-St Anthony Hospital
Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998
Lets Finish upLets Finish up
Be ProfessionalBe Professional AccurateAccurate ConsistentConsistent ThroughThrough ClearClear BriefBrief Paint the PicturePaint the Picture CollaborativeCollaborative
Legible spelling Legible spelling correctcorrect
Tell the TruthTell the Truth Donrsquot duplicate infoDonrsquot duplicate info Follow ProtocolsFollow Protocols Plain LanguagePlain Language Relevant InformationRelevant Information ldquoldquoThe JURYrdquoThe JURYrdquo Have your partner Have your partner
reviewreview
HIPPAHIPPA
What Happens on What Happens on the Ambulance the Ambulance stays on the stays on the ambulance ambulance
Health Health InsuranceInsurance PortabilityPortability PrivacyPrivacy AccountabilityAccountability
HIPPAHIPPA
Protects the security and privacy of Protects the security and privacy of all medical records and other health all medical records and other health information used or shared in any information used or shared in any formform
Protects patients rights by giving Protects patients rights by giving access to health information and access to health information and control over how it is usedcontrol over how it is used
PHIPHI Protected Heath InformationProtected Heath Information
Information that relates toInformation that relates to The health of an individualThe health of an individual Health care provided to that individualHealth care provided to that individual Payment of heath care providedPayment of heath care provided
What can be sharedWhat can be shared
Health Insurance Company my need Health Insurance Company my need information to process a claiminformation to process a claim
Caregivers involved with direct care Caregivers involved with direct care Quality Assurance when necessaryQuality Assurance when necessary
Special ConsiderationsSpecial Considerations
Exposure and InjuryExposure and Injury Mass CasualtyMass Casualty Interfacility TransportsInterfacility Transports RefusalsRefusals
Mass Casualty EventsMass Casualty Events
Documentation may have to be Documentation may have to be postponedpostponed
Follow Local Policy and ProcedureFollow Local Policy and Procedure Comprehensive run report must be Comprehensive run report must be
completed for each patient when completed for each patient when time permitstime permits
Refusal of CareRefusal of Care
Potential for LiabilityPotential for Liability Good DocumentationGood Documentation Make it clearMake it clear
Refusal of CareRefusal of Care
The litigation rate for EMS has been steadily increasing
1048657 According to one study patients evaluatedby paramedics but not transported to thehospital account for 50 to 90 of EMSlawsuitsrdquo
1048657 Documentation is your best defenserdquo
DocumentationDocumentation
Physical FindingsPhysical Findings The advice you give the patient about The advice you give the patient about
being transported and the associated being transported and the associated risks for not being transportedrisks for not being transported
Clinical indications that patient is Clinical indications that patient is competent to make a rational decisioncompetent to make a rational decision
Signatures of the patient and witnessSignatures of the patient and witness Full narrativeFull narrative Advise to call 911 if condition changesAdvise to call 911 if condition changes
Do not at any time attempt to talk the patient out of going to the hospital
If you feel strongly that the patient should be seen make every attempt to convince them they should be seen
Donrsquot say lsquo I agree you donrsquot need to gordquo even if you agree
What not to sayWhat not to say
A patient suffers a diabetic emergency She is treated by the local EMS crew with an A patient suffers a diabetic emergency She is treated by the local EMS crew with an IV an ampule of D50 and transported to the closet hospital despite family members IV an ampule of D50 and transported to the closet hospital despite family members telling you that the patient does not go theretelling you that the patient does not go there
Transport is uneventful and care is turned over to the ED Nurse with a quick verbal Transport is uneventful and care is turned over to the ED Nurse with a quick verbal reportreport
An hour later a private ambulance is called to transport the patient to her desired An hour later a private ambulance is called to transport the patient to her desired hospital for definitive care They notice the IV has infiltrated and D50 got into her hospital for definitive care They notice the IV has infiltrated and D50 got into her surrounding tissuessurrounding tissues
The patient suffers significant tissue damage which requires a fasciotomy to The patient suffers significant tissue damage which requires a fasciotomy to decompress her hand and forearm She has permanent nerve damage and requires decompress her hand and forearm She has permanent nerve damage and requires skin graftingskin grafting
Initial Transport Agency-CFDInitial Transport Agency-CFD
First Receiving Hospital-St Anthony HospitalFirst Receiving Hospital-St Anthony Hospital
Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998
Lets Finish upLets Finish up
Be ProfessionalBe Professional AccurateAccurate ConsistentConsistent ThroughThrough ClearClear BriefBrief Paint the PicturePaint the Picture CollaborativeCollaborative
Legible spelling Legible spelling correctcorrect
Tell the TruthTell the Truth Donrsquot duplicate infoDonrsquot duplicate info Follow ProtocolsFollow Protocols Plain LanguagePlain Language Relevant InformationRelevant Information ldquoldquoThe JURYrdquoThe JURYrdquo Have your partner Have your partner
reviewreview
HIPPAHIPPA
Protects the security and privacy of Protects the security and privacy of all medical records and other health all medical records and other health information used or shared in any information used or shared in any formform
Protects patients rights by giving Protects patients rights by giving access to health information and access to health information and control over how it is usedcontrol over how it is used
PHIPHI Protected Heath InformationProtected Heath Information
Information that relates toInformation that relates to The health of an individualThe health of an individual Health care provided to that individualHealth care provided to that individual Payment of heath care providedPayment of heath care provided
What can be sharedWhat can be shared
Health Insurance Company my need Health Insurance Company my need information to process a claiminformation to process a claim
Caregivers involved with direct care Caregivers involved with direct care Quality Assurance when necessaryQuality Assurance when necessary
Special ConsiderationsSpecial Considerations
Exposure and InjuryExposure and Injury Mass CasualtyMass Casualty Interfacility TransportsInterfacility Transports RefusalsRefusals
Mass Casualty EventsMass Casualty Events
Documentation may have to be Documentation may have to be postponedpostponed
Follow Local Policy and ProcedureFollow Local Policy and Procedure Comprehensive run report must be Comprehensive run report must be
completed for each patient when completed for each patient when time permitstime permits
Refusal of CareRefusal of Care
Potential for LiabilityPotential for Liability Good DocumentationGood Documentation Make it clearMake it clear
Refusal of CareRefusal of Care
The litigation rate for EMS has been steadily increasing
1048657 According to one study patients evaluatedby paramedics but not transported to thehospital account for 50 to 90 of EMSlawsuitsrdquo
1048657 Documentation is your best defenserdquo
DocumentationDocumentation
Physical FindingsPhysical Findings The advice you give the patient about The advice you give the patient about
being transported and the associated being transported and the associated risks for not being transportedrisks for not being transported
Clinical indications that patient is Clinical indications that patient is competent to make a rational decisioncompetent to make a rational decision
Signatures of the patient and witnessSignatures of the patient and witness Full narrativeFull narrative Advise to call 911 if condition changesAdvise to call 911 if condition changes
Do not at any time attempt to talk the patient out of going to the hospital
If you feel strongly that the patient should be seen make every attempt to convince them they should be seen
Donrsquot say lsquo I agree you donrsquot need to gordquo even if you agree
What not to sayWhat not to say
A patient suffers a diabetic emergency She is treated by the local EMS crew with an A patient suffers a diabetic emergency She is treated by the local EMS crew with an IV an ampule of D50 and transported to the closet hospital despite family members IV an ampule of D50 and transported to the closet hospital despite family members telling you that the patient does not go theretelling you that the patient does not go there
Transport is uneventful and care is turned over to the ED Nurse with a quick verbal Transport is uneventful and care is turned over to the ED Nurse with a quick verbal reportreport
An hour later a private ambulance is called to transport the patient to her desired An hour later a private ambulance is called to transport the patient to her desired hospital for definitive care They notice the IV has infiltrated and D50 got into her hospital for definitive care They notice the IV has infiltrated and D50 got into her surrounding tissuessurrounding tissues
The patient suffers significant tissue damage which requires a fasciotomy to The patient suffers significant tissue damage which requires a fasciotomy to decompress her hand and forearm She has permanent nerve damage and requires decompress her hand and forearm She has permanent nerve damage and requires skin graftingskin grafting
Initial Transport Agency-CFDInitial Transport Agency-CFD
First Receiving Hospital-St Anthony HospitalFirst Receiving Hospital-St Anthony Hospital
Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998
Lets Finish upLets Finish up
Be ProfessionalBe Professional AccurateAccurate ConsistentConsistent ThroughThrough ClearClear BriefBrief Paint the PicturePaint the Picture CollaborativeCollaborative
Legible spelling Legible spelling correctcorrect
Tell the TruthTell the Truth Donrsquot duplicate infoDonrsquot duplicate info Follow ProtocolsFollow Protocols Plain LanguagePlain Language Relevant InformationRelevant Information ldquoldquoThe JURYrdquoThe JURYrdquo Have your partner Have your partner
reviewreview
PHIPHI Protected Heath InformationProtected Heath Information
Information that relates toInformation that relates to The health of an individualThe health of an individual Health care provided to that individualHealth care provided to that individual Payment of heath care providedPayment of heath care provided
What can be sharedWhat can be shared
Health Insurance Company my need Health Insurance Company my need information to process a claiminformation to process a claim
Caregivers involved with direct care Caregivers involved with direct care Quality Assurance when necessaryQuality Assurance when necessary
Special ConsiderationsSpecial Considerations
Exposure and InjuryExposure and Injury Mass CasualtyMass Casualty Interfacility TransportsInterfacility Transports RefusalsRefusals
Mass Casualty EventsMass Casualty Events
Documentation may have to be Documentation may have to be postponedpostponed
Follow Local Policy and ProcedureFollow Local Policy and Procedure Comprehensive run report must be Comprehensive run report must be
completed for each patient when completed for each patient when time permitstime permits
Refusal of CareRefusal of Care
Potential for LiabilityPotential for Liability Good DocumentationGood Documentation Make it clearMake it clear
Refusal of CareRefusal of Care
The litigation rate for EMS has been steadily increasing
1048657 According to one study patients evaluatedby paramedics but not transported to thehospital account for 50 to 90 of EMSlawsuitsrdquo
1048657 Documentation is your best defenserdquo
DocumentationDocumentation
Physical FindingsPhysical Findings The advice you give the patient about The advice you give the patient about
being transported and the associated being transported and the associated risks for not being transportedrisks for not being transported
Clinical indications that patient is Clinical indications that patient is competent to make a rational decisioncompetent to make a rational decision
Signatures of the patient and witnessSignatures of the patient and witness Full narrativeFull narrative Advise to call 911 if condition changesAdvise to call 911 if condition changes
Do not at any time attempt to talk the patient out of going to the hospital
If you feel strongly that the patient should be seen make every attempt to convince them they should be seen
Donrsquot say lsquo I agree you donrsquot need to gordquo even if you agree
What not to sayWhat not to say
A patient suffers a diabetic emergency She is treated by the local EMS crew with an A patient suffers a diabetic emergency She is treated by the local EMS crew with an IV an ampule of D50 and transported to the closet hospital despite family members IV an ampule of D50 and transported to the closet hospital despite family members telling you that the patient does not go theretelling you that the patient does not go there
Transport is uneventful and care is turned over to the ED Nurse with a quick verbal Transport is uneventful and care is turned over to the ED Nurse with a quick verbal reportreport
An hour later a private ambulance is called to transport the patient to her desired An hour later a private ambulance is called to transport the patient to her desired hospital for definitive care They notice the IV has infiltrated and D50 got into her hospital for definitive care They notice the IV has infiltrated and D50 got into her surrounding tissuessurrounding tissues
The patient suffers significant tissue damage which requires a fasciotomy to The patient suffers significant tissue damage which requires a fasciotomy to decompress her hand and forearm She has permanent nerve damage and requires decompress her hand and forearm She has permanent nerve damage and requires skin graftingskin grafting
Initial Transport Agency-CFDInitial Transport Agency-CFD
First Receiving Hospital-St Anthony HospitalFirst Receiving Hospital-St Anthony Hospital
Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998
Lets Finish upLets Finish up
Be ProfessionalBe Professional AccurateAccurate ConsistentConsistent ThroughThrough ClearClear BriefBrief Paint the PicturePaint the Picture CollaborativeCollaborative
Legible spelling Legible spelling correctcorrect
Tell the TruthTell the Truth Donrsquot duplicate infoDonrsquot duplicate info Follow ProtocolsFollow Protocols Plain LanguagePlain Language Relevant InformationRelevant Information ldquoldquoThe JURYrdquoThe JURYrdquo Have your partner Have your partner
reviewreview
What can be sharedWhat can be shared
Health Insurance Company my need Health Insurance Company my need information to process a claiminformation to process a claim
Caregivers involved with direct care Caregivers involved with direct care Quality Assurance when necessaryQuality Assurance when necessary
Special ConsiderationsSpecial Considerations
Exposure and InjuryExposure and Injury Mass CasualtyMass Casualty Interfacility TransportsInterfacility Transports RefusalsRefusals
Mass Casualty EventsMass Casualty Events
Documentation may have to be Documentation may have to be postponedpostponed
Follow Local Policy and ProcedureFollow Local Policy and Procedure Comprehensive run report must be Comprehensive run report must be
completed for each patient when completed for each patient when time permitstime permits
Refusal of CareRefusal of Care
Potential for LiabilityPotential for Liability Good DocumentationGood Documentation Make it clearMake it clear
Refusal of CareRefusal of Care
The litigation rate for EMS has been steadily increasing
1048657 According to one study patients evaluatedby paramedics but not transported to thehospital account for 50 to 90 of EMSlawsuitsrdquo
1048657 Documentation is your best defenserdquo
DocumentationDocumentation
Physical FindingsPhysical Findings The advice you give the patient about The advice you give the patient about
being transported and the associated being transported and the associated risks for not being transportedrisks for not being transported
Clinical indications that patient is Clinical indications that patient is competent to make a rational decisioncompetent to make a rational decision
Signatures of the patient and witnessSignatures of the patient and witness Full narrativeFull narrative Advise to call 911 if condition changesAdvise to call 911 if condition changes
Do not at any time attempt to talk the patient out of going to the hospital
If you feel strongly that the patient should be seen make every attempt to convince them they should be seen
Donrsquot say lsquo I agree you donrsquot need to gordquo even if you agree
What not to sayWhat not to say
A patient suffers a diabetic emergency She is treated by the local EMS crew with an A patient suffers a diabetic emergency She is treated by the local EMS crew with an IV an ampule of D50 and transported to the closet hospital despite family members IV an ampule of D50 and transported to the closet hospital despite family members telling you that the patient does not go theretelling you that the patient does not go there
Transport is uneventful and care is turned over to the ED Nurse with a quick verbal Transport is uneventful and care is turned over to the ED Nurse with a quick verbal reportreport
An hour later a private ambulance is called to transport the patient to her desired An hour later a private ambulance is called to transport the patient to her desired hospital for definitive care They notice the IV has infiltrated and D50 got into her hospital for definitive care They notice the IV has infiltrated and D50 got into her surrounding tissuessurrounding tissues
The patient suffers significant tissue damage which requires a fasciotomy to The patient suffers significant tissue damage which requires a fasciotomy to decompress her hand and forearm She has permanent nerve damage and requires decompress her hand and forearm She has permanent nerve damage and requires skin graftingskin grafting
Initial Transport Agency-CFDInitial Transport Agency-CFD
First Receiving Hospital-St Anthony HospitalFirst Receiving Hospital-St Anthony Hospital
Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998
Lets Finish upLets Finish up
Be ProfessionalBe Professional AccurateAccurate ConsistentConsistent ThroughThrough ClearClear BriefBrief Paint the PicturePaint the Picture CollaborativeCollaborative
Legible spelling Legible spelling correctcorrect
Tell the TruthTell the Truth Donrsquot duplicate infoDonrsquot duplicate info Follow ProtocolsFollow Protocols Plain LanguagePlain Language Relevant InformationRelevant Information ldquoldquoThe JURYrdquoThe JURYrdquo Have your partner Have your partner
reviewreview
Special ConsiderationsSpecial Considerations
Exposure and InjuryExposure and Injury Mass CasualtyMass Casualty Interfacility TransportsInterfacility Transports RefusalsRefusals
Mass Casualty EventsMass Casualty Events
Documentation may have to be Documentation may have to be postponedpostponed
Follow Local Policy and ProcedureFollow Local Policy and Procedure Comprehensive run report must be Comprehensive run report must be
completed for each patient when completed for each patient when time permitstime permits
Refusal of CareRefusal of Care
Potential for LiabilityPotential for Liability Good DocumentationGood Documentation Make it clearMake it clear
Refusal of CareRefusal of Care
The litigation rate for EMS has been steadily increasing
1048657 According to one study patients evaluatedby paramedics but not transported to thehospital account for 50 to 90 of EMSlawsuitsrdquo
1048657 Documentation is your best defenserdquo
DocumentationDocumentation
Physical FindingsPhysical Findings The advice you give the patient about The advice you give the patient about
being transported and the associated being transported and the associated risks for not being transportedrisks for not being transported
Clinical indications that patient is Clinical indications that patient is competent to make a rational decisioncompetent to make a rational decision
Signatures of the patient and witnessSignatures of the patient and witness Full narrativeFull narrative Advise to call 911 if condition changesAdvise to call 911 if condition changes
Do not at any time attempt to talk the patient out of going to the hospital
If you feel strongly that the patient should be seen make every attempt to convince them they should be seen
Donrsquot say lsquo I agree you donrsquot need to gordquo even if you agree
What not to sayWhat not to say
A patient suffers a diabetic emergency She is treated by the local EMS crew with an A patient suffers a diabetic emergency She is treated by the local EMS crew with an IV an ampule of D50 and transported to the closet hospital despite family members IV an ampule of D50 and transported to the closet hospital despite family members telling you that the patient does not go theretelling you that the patient does not go there
Transport is uneventful and care is turned over to the ED Nurse with a quick verbal Transport is uneventful and care is turned over to the ED Nurse with a quick verbal reportreport
An hour later a private ambulance is called to transport the patient to her desired An hour later a private ambulance is called to transport the patient to her desired hospital for definitive care They notice the IV has infiltrated and D50 got into her hospital for definitive care They notice the IV has infiltrated and D50 got into her surrounding tissuessurrounding tissues
The patient suffers significant tissue damage which requires a fasciotomy to The patient suffers significant tissue damage which requires a fasciotomy to decompress her hand and forearm She has permanent nerve damage and requires decompress her hand and forearm She has permanent nerve damage and requires skin graftingskin grafting
Initial Transport Agency-CFDInitial Transport Agency-CFD
First Receiving Hospital-St Anthony HospitalFirst Receiving Hospital-St Anthony Hospital
Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998
Lets Finish upLets Finish up
Be ProfessionalBe Professional AccurateAccurate ConsistentConsistent ThroughThrough ClearClear BriefBrief Paint the PicturePaint the Picture CollaborativeCollaborative
Legible spelling Legible spelling correctcorrect
Tell the TruthTell the Truth Donrsquot duplicate infoDonrsquot duplicate info Follow ProtocolsFollow Protocols Plain LanguagePlain Language Relevant InformationRelevant Information ldquoldquoThe JURYrdquoThe JURYrdquo Have your partner Have your partner
reviewreview
Mass Casualty EventsMass Casualty Events
Documentation may have to be Documentation may have to be postponedpostponed
Follow Local Policy and ProcedureFollow Local Policy and Procedure Comprehensive run report must be Comprehensive run report must be
completed for each patient when completed for each patient when time permitstime permits
Refusal of CareRefusal of Care
Potential for LiabilityPotential for Liability Good DocumentationGood Documentation Make it clearMake it clear
Refusal of CareRefusal of Care
The litigation rate for EMS has been steadily increasing
1048657 According to one study patients evaluatedby paramedics but not transported to thehospital account for 50 to 90 of EMSlawsuitsrdquo
1048657 Documentation is your best defenserdquo
DocumentationDocumentation
Physical FindingsPhysical Findings The advice you give the patient about The advice you give the patient about
being transported and the associated being transported and the associated risks for not being transportedrisks for not being transported
Clinical indications that patient is Clinical indications that patient is competent to make a rational decisioncompetent to make a rational decision
Signatures of the patient and witnessSignatures of the patient and witness Full narrativeFull narrative Advise to call 911 if condition changesAdvise to call 911 if condition changes
Do not at any time attempt to talk the patient out of going to the hospital
If you feel strongly that the patient should be seen make every attempt to convince them they should be seen
Donrsquot say lsquo I agree you donrsquot need to gordquo even if you agree
What not to sayWhat not to say
A patient suffers a diabetic emergency She is treated by the local EMS crew with an A patient suffers a diabetic emergency She is treated by the local EMS crew with an IV an ampule of D50 and transported to the closet hospital despite family members IV an ampule of D50 and transported to the closet hospital despite family members telling you that the patient does not go theretelling you that the patient does not go there
Transport is uneventful and care is turned over to the ED Nurse with a quick verbal Transport is uneventful and care is turned over to the ED Nurse with a quick verbal reportreport
An hour later a private ambulance is called to transport the patient to her desired An hour later a private ambulance is called to transport the patient to her desired hospital for definitive care They notice the IV has infiltrated and D50 got into her hospital for definitive care They notice the IV has infiltrated and D50 got into her surrounding tissuessurrounding tissues
The patient suffers significant tissue damage which requires a fasciotomy to The patient suffers significant tissue damage which requires a fasciotomy to decompress her hand and forearm She has permanent nerve damage and requires decompress her hand and forearm She has permanent nerve damage and requires skin graftingskin grafting
Initial Transport Agency-CFDInitial Transport Agency-CFD
First Receiving Hospital-St Anthony HospitalFirst Receiving Hospital-St Anthony Hospital
Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998
Lets Finish upLets Finish up
Be ProfessionalBe Professional AccurateAccurate ConsistentConsistent ThroughThrough ClearClear BriefBrief Paint the PicturePaint the Picture CollaborativeCollaborative
Legible spelling Legible spelling correctcorrect
Tell the TruthTell the Truth Donrsquot duplicate infoDonrsquot duplicate info Follow ProtocolsFollow Protocols Plain LanguagePlain Language Relevant InformationRelevant Information ldquoldquoThe JURYrdquoThe JURYrdquo Have your partner Have your partner
reviewreview
Refusal of CareRefusal of Care
Potential for LiabilityPotential for Liability Good DocumentationGood Documentation Make it clearMake it clear
Refusal of CareRefusal of Care
The litigation rate for EMS has been steadily increasing
1048657 According to one study patients evaluatedby paramedics but not transported to thehospital account for 50 to 90 of EMSlawsuitsrdquo
1048657 Documentation is your best defenserdquo
DocumentationDocumentation
Physical FindingsPhysical Findings The advice you give the patient about The advice you give the patient about
being transported and the associated being transported and the associated risks for not being transportedrisks for not being transported
Clinical indications that patient is Clinical indications that patient is competent to make a rational decisioncompetent to make a rational decision
Signatures of the patient and witnessSignatures of the patient and witness Full narrativeFull narrative Advise to call 911 if condition changesAdvise to call 911 if condition changes
Do not at any time attempt to talk the patient out of going to the hospital
If you feel strongly that the patient should be seen make every attempt to convince them they should be seen
Donrsquot say lsquo I agree you donrsquot need to gordquo even if you agree
What not to sayWhat not to say
A patient suffers a diabetic emergency She is treated by the local EMS crew with an A patient suffers a diabetic emergency She is treated by the local EMS crew with an IV an ampule of D50 and transported to the closet hospital despite family members IV an ampule of D50 and transported to the closet hospital despite family members telling you that the patient does not go theretelling you that the patient does not go there
Transport is uneventful and care is turned over to the ED Nurse with a quick verbal Transport is uneventful and care is turned over to the ED Nurse with a quick verbal reportreport
An hour later a private ambulance is called to transport the patient to her desired An hour later a private ambulance is called to transport the patient to her desired hospital for definitive care They notice the IV has infiltrated and D50 got into her hospital for definitive care They notice the IV has infiltrated and D50 got into her surrounding tissuessurrounding tissues
The patient suffers significant tissue damage which requires a fasciotomy to The patient suffers significant tissue damage which requires a fasciotomy to decompress her hand and forearm She has permanent nerve damage and requires decompress her hand and forearm She has permanent nerve damage and requires skin graftingskin grafting
Initial Transport Agency-CFDInitial Transport Agency-CFD
First Receiving Hospital-St Anthony HospitalFirst Receiving Hospital-St Anthony Hospital
Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998
Lets Finish upLets Finish up
Be ProfessionalBe Professional AccurateAccurate ConsistentConsistent ThroughThrough ClearClear BriefBrief Paint the PicturePaint the Picture CollaborativeCollaborative
Legible spelling Legible spelling correctcorrect
Tell the TruthTell the Truth Donrsquot duplicate infoDonrsquot duplicate info Follow ProtocolsFollow Protocols Plain LanguagePlain Language Relevant InformationRelevant Information ldquoldquoThe JURYrdquoThe JURYrdquo Have your partner Have your partner
reviewreview
Refusal of CareRefusal of Care
The litigation rate for EMS has been steadily increasing
1048657 According to one study patients evaluatedby paramedics but not transported to thehospital account for 50 to 90 of EMSlawsuitsrdquo
1048657 Documentation is your best defenserdquo
DocumentationDocumentation
Physical FindingsPhysical Findings The advice you give the patient about The advice you give the patient about
being transported and the associated being transported and the associated risks for not being transportedrisks for not being transported
Clinical indications that patient is Clinical indications that patient is competent to make a rational decisioncompetent to make a rational decision
Signatures of the patient and witnessSignatures of the patient and witness Full narrativeFull narrative Advise to call 911 if condition changesAdvise to call 911 if condition changes
Do not at any time attempt to talk the patient out of going to the hospital
If you feel strongly that the patient should be seen make every attempt to convince them they should be seen
Donrsquot say lsquo I agree you donrsquot need to gordquo even if you agree
What not to sayWhat not to say
A patient suffers a diabetic emergency She is treated by the local EMS crew with an A patient suffers a diabetic emergency She is treated by the local EMS crew with an IV an ampule of D50 and transported to the closet hospital despite family members IV an ampule of D50 and transported to the closet hospital despite family members telling you that the patient does not go theretelling you that the patient does not go there
Transport is uneventful and care is turned over to the ED Nurse with a quick verbal Transport is uneventful and care is turned over to the ED Nurse with a quick verbal reportreport
An hour later a private ambulance is called to transport the patient to her desired An hour later a private ambulance is called to transport the patient to her desired hospital for definitive care They notice the IV has infiltrated and D50 got into her hospital for definitive care They notice the IV has infiltrated and D50 got into her surrounding tissuessurrounding tissues
The patient suffers significant tissue damage which requires a fasciotomy to The patient suffers significant tissue damage which requires a fasciotomy to decompress her hand and forearm She has permanent nerve damage and requires decompress her hand and forearm She has permanent nerve damage and requires skin graftingskin grafting
Initial Transport Agency-CFDInitial Transport Agency-CFD
First Receiving Hospital-St Anthony HospitalFirst Receiving Hospital-St Anthony Hospital
Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998
Lets Finish upLets Finish up
Be ProfessionalBe Professional AccurateAccurate ConsistentConsistent ThroughThrough ClearClear BriefBrief Paint the PicturePaint the Picture CollaborativeCollaborative
Legible spelling Legible spelling correctcorrect
Tell the TruthTell the Truth Donrsquot duplicate infoDonrsquot duplicate info Follow ProtocolsFollow Protocols Plain LanguagePlain Language Relevant InformationRelevant Information ldquoldquoThe JURYrdquoThe JURYrdquo Have your partner Have your partner
reviewreview
DocumentationDocumentation
Physical FindingsPhysical Findings The advice you give the patient about The advice you give the patient about
being transported and the associated being transported and the associated risks for not being transportedrisks for not being transported
Clinical indications that patient is Clinical indications that patient is competent to make a rational decisioncompetent to make a rational decision
Signatures of the patient and witnessSignatures of the patient and witness Full narrativeFull narrative Advise to call 911 if condition changesAdvise to call 911 if condition changes
Do not at any time attempt to talk the patient out of going to the hospital
If you feel strongly that the patient should be seen make every attempt to convince them they should be seen
Donrsquot say lsquo I agree you donrsquot need to gordquo even if you agree
What not to sayWhat not to say
A patient suffers a diabetic emergency She is treated by the local EMS crew with an A patient suffers a diabetic emergency She is treated by the local EMS crew with an IV an ampule of D50 and transported to the closet hospital despite family members IV an ampule of D50 and transported to the closet hospital despite family members telling you that the patient does not go theretelling you that the patient does not go there
Transport is uneventful and care is turned over to the ED Nurse with a quick verbal Transport is uneventful and care is turned over to the ED Nurse with a quick verbal reportreport
An hour later a private ambulance is called to transport the patient to her desired An hour later a private ambulance is called to transport the patient to her desired hospital for definitive care They notice the IV has infiltrated and D50 got into her hospital for definitive care They notice the IV has infiltrated and D50 got into her surrounding tissuessurrounding tissues
The patient suffers significant tissue damage which requires a fasciotomy to The patient suffers significant tissue damage which requires a fasciotomy to decompress her hand and forearm She has permanent nerve damage and requires decompress her hand and forearm She has permanent nerve damage and requires skin graftingskin grafting
Initial Transport Agency-CFDInitial Transport Agency-CFD
First Receiving Hospital-St Anthony HospitalFirst Receiving Hospital-St Anthony Hospital
Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998
Lets Finish upLets Finish up
Be ProfessionalBe Professional AccurateAccurate ConsistentConsistent ThroughThrough ClearClear BriefBrief Paint the PicturePaint the Picture CollaborativeCollaborative
Legible spelling Legible spelling correctcorrect
Tell the TruthTell the Truth Donrsquot duplicate infoDonrsquot duplicate info Follow ProtocolsFollow Protocols Plain LanguagePlain Language Relevant InformationRelevant Information ldquoldquoThe JURYrdquoThe JURYrdquo Have your partner Have your partner
reviewreview
Do not at any time attempt to talk the patient out of going to the hospital
If you feel strongly that the patient should be seen make every attempt to convince them they should be seen
Donrsquot say lsquo I agree you donrsquot need to gordquo even if you agree
What not to sayWhat not to say
A patient suffers a diabetic emergency She is treated by the local EMS crew with an A patient suffers a diabetic emergency She is treated by the local EMS crew with an IV an ampule of D50 and transported to the closet hospital despite family members IV an ampule of D50 and transported to the closet hospital despite family members telling you that the patient does not go theretelling you that the patient does not go there
Transport is uneventful and care is turned over to the ED Nurse with a quick verbal Transport is uneventful and care is turned over to the ED Nurse with a quick verbal reportreport
An hour later a private ambulance is called to transport the patient to her desired An hour later a private ambulance is called to transport the patient to her desired hospital for definitive care They notice the IV has infiltrated and D50 got into her hospital for definitive care They notice the IV has infiltrated and D50 got into her surrounding tissuessurrounding tissues
The patient suffers significant tissue damage which requires a fasciotomy to The patient suffers significant tissue damage which requires a fasciotomy to decompress her hand and forearm She has permanent nerve damage and requires decompress her hand and forearm She has permanent nerve damage and requires skin graftingskin grafting
Initial Transport Agency-CFDInitial Transport Agency-CFD
First Receiving Hospital-St Anthony HospitalFirst Receiving Hospital-St Anthony Hospital
Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998
Lets Finish upLets Finish up
Be ProfessionalBe Professional AccurateAccurate ConsistentConsistent ThroughThrough ClearClear BriefBrief Paint the PicturePaint the Picture CollaborativeCollaborative
Legible spelling Legible spelling correctcorrect
Tell the TruthTell the Truth Donrsquot duplicate infoDonrsquot duplicate info Follow ProtocolsFollow Protocols Plain LanguagePlain Language Relevant InformationRelevant Information ldquoldquoThe JURYrdquoThe JURYrdquo Have your partner Have your partner
reviewreview
A patient suffers a diabetic emergency She is treated by the local EMS crew with an A patient suffers a diabetic emergency She is treated by the local EMS crew with an IV an ampule of D50 and transported to the closet hospital despite family members IV an ampule of D50 and transported to the closet hospital despite family members telling you that the patient does not go theretelling you that the patient does not go there
Transport is uneventful and care is turned over to the ED Nurse with a quick verbal Transport is uneventful and care is turned over to the ED Nurse with a quick verbal reportreport
An hour later a private ambulance is called to transport the patient to her desired An hour later a private ambulance is called to transport the patient to her desired hospital for definitive care They notice the IV has infiltrated and D50 got into her hospital for definitive care They notice the IV has infiltrated and D50 got into her surrounding tissuessurrounding tissues
The patient suffers significant tissue damage which requires a fasciotomy to The patient suffers significant tissue damage which requires a fasciotomy to decompress her hand and forearm She has permanent nerve damage and requires decompress her hand and forearm She has permanent nerve damage and requires skin graftingskin grafting
Initial Transport Agency-CFDInitial Transport Agency-CFD
First Receiving Hospital-St Anthony HospitalFirst Receiving Hospital-St Anthony Hospital
Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998
Lets Finish upLets Finish up
Be ProfessionalBe Professional AccurateAccurate ConsistentConsistent ThroughThrough ClearClear BriefBrief Paint the PicturePaint the Picture CollaborativeCollaborative
Legible spelling Legible spelling correctcorrect
Tell the TruthTell the Truth Donrsquot duplicate infoDonrsquot duplicate info Follow ProtocolsFollow Protocols Plain LanguagePlain Language Relevant InformationRelevant Information ldquoldquoThe JURYrdquoThe JURYrdquo Have your partner Have your partner
reviewreview
Lets Finish upLets Finish up
Be ProfessionalBe Professional AccurateAccurate ConsistentConsistent ThroughThrough ClearClear BriefBrief Paint the PicturePaint the Picture CollaborativeCollaborative
Legible spelling Legible spelling correctcorrect
Tell the TruthTell the Truth Donrsquot duplicate infoDonrsquot duplicate info Follow ProtocolsFollow Protocols Plain LanguagePlain Language Relevant InformationRelevant Information ldquoldquoThe JURYrdquoThe JURYrdquo Have your partner Have your partner
reviewreview