Patient Care Documentation“A Proactive Approach”

- Richard W. Patrick, B.S., EMT-P/FF

- Steven A. Forry, EMT-P

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Objectives

State the importance and benefits of professional patient care documentation.

Understand the importance of following treatment protocols and standing orders.

Differentiate the criminal, civil, and ethical implications of patient care documentation.

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Objectives Con’t

Understand the responsibility to properly assess, treat, stabilize, transport, and document the care provided to their patient, as identified in their scope of practice and within their standard of care.

Develop a methodology for obtaining objective and subjective patient care information using open and closed ended questions.

State the differences in civil, criminal, and possibly punitive aspects of alleged malpractice.

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Objectives Con’t

Recognize the value of prospective, concurrent, and retrospective continuous quality improvement through positive rather than negative reinforcement and disciplinary action.

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Identifying the Problem

Trip Sheet

Vs.

Patient Care Report

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Scenario #1

53 y/o male, c/o SOB PMH: CHF MEDS: Lasix Allergies: None Vital Signs:

– 162/88, P-112, R-38– 168/90, P-124, R-36

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Identifying the Problem

Coupled to the need for quality patient care is the need for appropriate and thorough documentation of your findings

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Identifying the Problem

“a properly completed PCR can prevent a prehospital care provider from being sued, or, in the event that an incident is litigated, can dramatically improve the providers chances of winning the lawsuit.”

- Richard A. Lazar, JD

- Robert J. Schappert III

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Identifying the Problem

“if the EMS training institutions have failed to adequately teach EMT students to document, they likely have also failed to establish standards for the profession of prehospital care.”

- The American College of Emergency Physicians

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Bad Trip Sheet

Identify the problems.

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“Bloopers”

Patient is able to remove his neck, but it does cause some discomfort.

Patient has two teenage children but no other abnormalities Explained to the family that patient was at death’s door and

we were trying to pull him through Patient suffered cardiac arrest. Resuscitation attempts failed

and patient pronounced dead. Patient requests an autopsy. Skin: Somewhat pale, but present. On the second day, the knee was better, and on the third

day, it had completely disappeared.

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Patient Assessment & Documentation

Illness Assessment– Head to Toe

Injury Assessment– Head to Toe

Acronyms

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Patient Care Documentation

PCR must be completed on every call PCR must be complete for every call Proper abbreviations, words, and

attitude Readable, professional, and adequately

reflect the care given or offered to patient

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Patient Care Documentation

Quotes where appropriate and required

Copy given in receiving hospital for attaching to permanent medical record.

Refusal form and incident report completed

“If you didn’t write it,

you didn’t do it!”

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Patient Refusals

First we must understand that a competent adult has the right to refuse treatment and/or transportation.

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Patient Refusals

The EMS Providers Challenge:

To distinguish incompetence from bad decision-making.

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Patient Refusals

Patients who request to sign AMA Patients who are allowed to sign AMA Patient requests treatment - but no

transport Patient requests transport - but no

treatment

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Patient Refusals

Patients who should go to a hospital

Patients who must go to a hospital Patients with life threatening

illness/injury

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Patient Refusals

The EMS provider must always keep the best interest of the patient at the forefront

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Refusal Information Sheet

A document that provides information to the victim/patient regarding their refusal of services and offers added protection to the EMS provider.

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Refusal Check List

This check list is used to assist the EMS provider in a systematic approach to assure all venues have been exhausted during the consideration of patient refusals.

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Patient Evaluation Sheet

The EMS Cognitive Evaluation sheet assists with “elements of perception” in the determination of the victim/patients level of competence.

“Raise your right hand”

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Service Transport Form

Competent patients maintain the right to refuse medical care and/or transportation. This sample Refusal of Service/Transport form builds from previous examples to aid EMS providers when attempts to treat/transport have been exhausted.

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The Patient Care Report

Misspelled words, illegible hand-writing, and poor writing skills lend themselves to questioning the credibility of the care provider

“Just the Facts Ma’am”

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Scenario #2

76 y/o female c/o chest pain, nauseated, and dizzy.

PMH: Angina, Gall Bladder Operation

MEDS: Nitro, ASA, Vitamins Allergies: PCN Vital Signs:

– 204/98, P-56, R-28– 198/92, P-52, R-24

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Sample Patient Care Report Form

Although Patient Care Report forms vary in design, content is often the same. Several PCR’s are available for review and discussion.

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Scenario #3

26 y/o male walking around acting inappropriately post MVA.

Victim is bleeding from head.

Possible alcohol consumption

PMH: unknown Vitals: Victim does not

permit V.S. to be taken.

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Patient Care Report Form

Upon call completion, fill out your PCR and any applicable

documents.

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EMS Report Form

The PCR provides important data for EMS Operations!

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Scenario #4

66 y/o male c/o tightness in his chest.

He permits Rx but refuses Tx. PMH: Angina, Gall Bladder

surgery 10 years ago. Meds: Nitrostat, ASA Allergies: MS Vitals:

188/98, P-116, R-24

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Incident Reports

Treatment Errors Equipment Malfunctions

– Medical Devices Act

Domestic Situations Vehicle Malfunctions/Crashes Other

– Infectious Disease Exposure, etc...

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Incident Report FormIncident ReportReference Number: _________________ Date: ______________ Shift: 24-08; 08-16; 16-24Incident Type: ________________________________________________________________________Unit #: __________ Time of Incident: _________ Time of Report: _________Personnel Involved: ___________________________________

_________________________________________________________________________________________________________

Incident Description:__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

(continue on separate sheet if necessary)

__________________________________ ___________________________________Signature: Provider completing Report Signature: Supervisor receiving Report--------------------------------------------------------------------------------------------------------------------------------

-Department Use Only-

Resolution: Date: ___________ Time: ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

__________________________________ ____________________________________Signature: Investigating Supervisor Signature: Chief of Operations

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Medical Direction

Medical Direction is not only a necessity but an asset to any EMS organization.

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Medical Direction

On - Line Medical Direction

vs.

Off - Line Medical Direction

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The Quality Process

Quality Assurance

&

Continuous Quality Improvement

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The Quality Process

EMS personnel should consider the Quality Process as an intricate part of their everyday function.

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The Quality Process

The Seven Key Action Areas

1. Leadership

2. Information & Analysis

3. Strategic Quality Planning

4. Human Resource Development and Management

5. EMS Process Management

6. EMS System Results

7. Satisfaction of Patients and Other Stakeholders

-Malcolm Baldridge Quality Program

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Summary- What Can/Should We do?

Prospective QA/QI Active Medical

Director Peer performance

reviews Regular case reviews Protocol

review/testing

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Summary- What Can/Should We do? (con’t) Computer based PCR

w/ protocol compliance

PCR reviews - staggered by length of experience

Skills review & testing

“If you didn’t write it,

you didn’t do it!”

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Dare To Be Different From Everyone Else!

Do What’s Right!

Questions & Answers

THANKS FOR SHARING YOUR TIME !!