Documentation

Brown EMS

October 18, 2007

Reasons for Documentation

• Continuation of care– Medications– Physical exam findings, trends

• Continuous Quality Improvement

• Protocol adherence

• Legal Protection

If you didn’t write it down it didn’t happen

A good report is…

• Concise

• Accurate

• Consistent in style

• Addresses chief complaint

• Demonstrates professional and appropriate care of patient

Styles

SOAP

• Subjective- symptoms

• Objective- physical exam, vital signs

• Assessment- differential diagnosis

• Plan- treatment, follow up

Review of Systems

• General appearance, skin color, level of distress• HEENT head, ears, eyes, nose and throat• Neuro- A+Ox3, pupils, gait, speech, affect,

intoxication• Cardiovascular- HR, BP, Heart sounds, JVD,• Pulmonary- lung sounds, RR, percussion, SpO2• GI/GU- palpation, • Musculoskeletal- fractures, strength, • Integumentary

Physical exam techniques

• Inspect

• Palpate

• Percuss

• Auscultate (before palpate on abdominal exam)

Head to toe exam

• Mental status A+Ox3, PERRL, gait, speech

• Skin – Warm, Dry, Color – Normal, rashes?

• Head- trauma, airway• Neck- trauma, (c spine) tenderness, stridor, JVD, trachea midline

• Chest- lung sounds, trauma, heart sounds, percuss,

• Abdomen- soft, tender, masses, pulsations, scars

• Pelvis- Stable, tenderness

• Extremeties- distal csm, trauma

General EMS Report format• Chief complaint• Meds• PMH• Allergies

• Circumstances of call (dispatch, location)• HPI (Symptoms)• PE (Signs)• Tx (includes transport or refusal)• Response to Tx

Chief Complaint

• Why is the patient seeking medical care

• Use the patient’s own words if possible

History of Present Illness

• Details about the chief complaint

• Includes pertinent negatives

• Pertinent negatives- important information that helps narrow your differential diagnosis

Some important mnemonics

PAIN• OPQRST

– Onset– Provocation– Quality – Radiation– Severity– Timing

PHTLS• AMPLE

– Allergies– Medications– Past Medical History– Last Meal– Events preceding

Medical History

• Surgical history

• OB History (if related to chief complaint)

• Family history

• Medications and allergies

• Major illnesses

• Current ongoing illness

Vital Signs

• BP

• Pulse - rate, regularity, quality

• Respiration Rate

• Temperature - specify route, PO/PR

• Pain, 1-10

• Glucose

• SpO2

Physical exam findings

• Mental status• Skin• Pupils• Neuro• Lung sounds• Chest• Abdomen

• Exam should be focused on chief complaint

• All documentation should include mental status, general appearance.

Treatment

• Exam findings should support treatment

• CSM before & after splinting / c spine

• Meds: time, dose, route

• Response to treatment

• Transport

Chest pain differential diagnosis

• Cardiac– MI, angina, pericarditis

• Aortic Aneurysm

• Pulmonary– Pneumonia, Pulmonary Embolism,

Pneumothorax

• Musculoskeletal

• GI

Chest pain/cardiac

• OPQRST• Shortness of breath• Nausea /Vomiting• Weakness, dizziness• Diaphoresis• Orthopnea• Nocturnal dyspnea• Past MI, FHx• ?diabetes

• Lung sounds• JVD• EKG• BP, HR, RR• Pulses• Cap refill• Skin color, condition• edema

Trauma Differential

• Head injury/bleed

• Airway compromise

• C spine fracture

• Pneumothorax

• Hemorrhage / hypotension

• GSW, stab wounds, occult injuries

• ETC.

Trauma• AMPLE• Mechanism of injury

– Speed, type of vehicle, restrained, helmet

• Ambulatory?• LOC• Change in mental

status• vomiting

• Airway• Lung sounds• Mental status• C spine• Vital signs• PERRL• Head, neck• Chest and back• Pelvis• Extremeties- csm,

trauma

Abdominal pain differential

• Appendicitis• Ectopic pregnancy or

other OB emergency• Ischemic bowel• AAA• Ulcer• Esophageal varicies• Pancreatitis

• Trauma (spleen)• GERD• Infection/ food

poisoning• Gastritis• Renal

• Location, location…

Abdominal pain

• Surgeries• OPQRST• Nausea, vomiting

diarrhea• Recent meals• Pregnancy• Last bowel movement• Last Menstrual Period• Unusual bleeding

• Mental status• Skin color, temp• PO temp• Bowel sounds• Soft, rigid, masses,

pulsation, tenderness, guarding

• Rebound tenderness• Distal pulses-

femoral, pedal

Headache differential

• Head bleed, CVA• trauma• Migraine• Stress

Headache

• Trauma• Photophobia• Nausea/ vomiting• Stiff neck, back• Fever• LOC• Visual problems• PEERL• OTC meds• Coumadin?

Head Injury

• Trauma• Photophobia• Nausea/ vomiting• Stiff neck, back• Fever• LOC• Visual problems• PEERL• OTC meds• Coumadin?• ETOH

Refusal• Must be well documented

• Thorough history and physical exam

• Complete vital signs

• Against medical advice

• Notification of risks including death or disability by refusing care

• Signs and symptoms to look for

• Follow up instructions given to patient

Things to avoid

• Exam was unremarkable

• Pt was intoxicated…refused treatment

• Anything crossed out or added in report. If you need to add information add it at the end N.B.

• Treatment inconsistent with report.

• Incomplete vitals

Bubbles• Research code -

undergrad, grad, faculty, etc. list is posted in supervisors office

• Census tract - East or West of Thayer St.

• Service Number- 0092

• VHCL# - 01 or 02

• Please fill in all appropriate fields

• Fill in bubbles completely

• Only one primary suspected illness