chapter 14 documentation “if it’s not written down, you didn’t do it!!!”
TRANSCRIPT
CHAPTER 14
Documentation
“If it’s not written down, you didn’t do
it!!!”
Minimum DataPatient Information
Patient InformationGathered at the time of the EMT–B’s initial contact with patient on arrival at scene, following all interventions, and on arrival at facility
Chief complaint/what the patient tells you is wrong/why EMS was called
Level of consciousness (AVPU), mental status
Systolic BP for patients greater than 3 years old
Minimum DataPatient Information
Continued…
Skin perfusion (capillary refill) for patients less than 6 years old
Skin color and temperature
Pulse rate/quality
Respiratory rate and effort
Minimum DataPatient Information
Minimum Data Administrative Information
Administrative InformationTime incident reported
Time unit notified
Time of arrival at patient
Time unit left scene
Time of arrival at destination
Time of transfer of care
Minimum DataAccurate and Synchronous Clocks
Accurate and Synchronous Clocks
Always use times that dispatch gives you because there could be a difference of several minutes between your watch or the ambulance clock. You want to make sure that you are being consistent and that your PCR matches the dispatch records.
The Prehospital The Prehospital Care Report (PCR)Care Report (PCR)
Prehospital Care Report:Functions
Continuity of care – a form that is not read
immediately in the emergency department may very well be referred to later for important information
Legal document – could be called to court
A good report has documented what emergency medical care was provided and the status of the patient on arrival at the scene and any changes upon arrival at the receiving facility
The person who completed the form ordinarily must go to court with the form
Information should include objective and subjective information and be clear; there should be no opinions, and you should write neatly and succinctly
Prehospital Care Report:Functions
Educational – used to demonstrate proper documentation and how to handle unusual or uncommon cases
Administrative
Billing information
Service Statistics
Prehospital Care Report:Functions
Research – to improve response times/scheduling/deployment, etc…
Evaluation and Continuous Quality Improvement – look at poor/excellent patient care
Conformity or Patient Care Standards – calls are routinely reviewed for conformity to current medical and organizational standards
Prehospital Prehospital Care Report Care Report (Handwritten)(Handwritten)
Traditional written Traditional written form with check boxes form with check boxes
and a section for a and a section for a narrativenarrative
Prehospital Prehospital Care Report Care Report (Computerized)(Computerized)
Pen-Based Computer and PDAPen-Based Computer and PDA
Computerized version where Computerized version where information is filled in by a means of information is filled in by a means of an electronic clipboard or a similar an electronic clipboard or a similar
devicedevice
PCR Data Set
Each piece of information is an element (i.e. vital signs).
U.S. DOT defines minimum elements for a PCR.
Data Sections of the PCR
Run DataRun Data
Includes date, times (rely on dispatcher for these), service, unit, names of crew, agency name, location of call
Patient DataPatient Data
Patient name, address, date of birth, race, chief complaint (put in quotes), patient’s medications, insurance information/billing, sex,
age, nature of call, mechanism of injury, location of patient, treatment administered prior to arrival of EMT-Basic, signs and
symptoms, care administered, baseline vital signs, SAMPLE History and changes in condition
Check BoxesCheck Boxes
•Efficient method
•Be sure to fill in box completely/you may be able to write a few words
•Avoid stray marks
NarrativeNarrative
Narrative
Describe, don’t conclude; be objective (include presentation, assessment findings, treatment, transport information
Include pertinent negatives
Record important observations about the scene (i.e. suicide note, weapon, etc…)
Narrative Avoid slang and radio codes.
Use abbreviations only if they are standard
When information of a sensitive nature is documented, note the source of that information (i.e. communicable diseases)
State reporting requirements
Use correct spelling, especially medical terminology. If you do not know how to spell it, find out or use another word. Also, if explanation can be made clearer with plain English, use it. Make sure you know the meaning of what you are writing because if you do not, it could result in loss of credibility, embarrassment, and have a negative impact on patient care
For every reassessment, record time (military) and findings
Write legibly.
Prehospital Care Report
ConfidentialityThe form itself and the information on the form are considered confidential. Be familiar with your state laws
Regulated by Health Insurance Portability Accessibility Act (HIPAA)
Must keep completed reports in locked box
Distribution of copiesDetermined by local & state protocol and procedures will determine where the different copies of the form should be distributed
A copy will be filed with your agency, a copy will be sent to the state, and a copy will be left with the hospital ER; no other copies should be distributed without written authorization and subpoena
Falsification of PCR
When an error of omission or commission occurs, the EMT-Basic should not try to cover it up. Instead, document what did or did not happen and what steps were taken (if any) to correct the situation
omission – those in which an important part of the assessment or care was left out
commission – actions performed on the patient that are wrong or improper
Falsification of information on the PCR may lead not only to suspension or revocation of the EMT-Basic’s certification/license, but also to poor patient care because other health care providers have a false impression of which assessment findings were discovered or what treatment was given
Continued…
Specific areas of difficulty
Vital Signs – document only the vital signs that were actually taken (if you didn’t have time, don’t make them up)
Treatment – if a treatment like oxygen was overlooked, do not chart that the patient was given oxygen
Falsification of PCR
Patient Refusal
Competent adult patients may legally refuse treatment.
Age?
Impaired by alcohol/drugs?
Mentally competent?
Impaired by medical condition?
Before the EMT-Basic leaves the scene, however, he should:
Try again to persuade the patient to go to a hospital
Ensure the patient is able to make an informed, rational decision (i.e. not under the influence of alcohol or other drugs, or illness/injury effects – mental status).
Inform the patient why he should go and what may happen if he does not
Consult medical direction as directed by local protocol
If the patient still refuses, document all assessment findings and emergency medical care given, then have the patient sign a refusal form (also write in narrative section of PCR).
Have family member, police officer or bystander sign the form as a witness. If the patient refuses to sign the refusal form, have a family member, police officer or bystander sign the form verifying that the patient refused to sign.
Patient Refusal
Complete the pre-hospital care report
Complete patient assessment
Care EMT-Basic wished to provide for the patient. This is a common situation where an EMT may be held liable.
State that the EMT-Basic explained to the patient the possible consequences of failure to accept care, including potential death
Offer alternative methods of gaining care
State willingness to return.
Patient Refusal
SpecialSpecialDocumentationDocumentation
IssuesIssues
Correction of Errors
Errors discovered while the report form is being written (before it is distributed to anyone)
Draw a single horizontal line through the error, initial it, and write the correct information beside it.
Do not obliterate the error – this may be seen as an attempt to cover up a mistake.
Cross out error and initialCross out error and initial
If an error is discovered after form is submitted:
Preferably, in a different color of ink, draw a single line through the error, initial and date it, and add a note with the correct information
If information was omitted, add a note with the correct information, the date and the EMT-Basic’s initials.
Correction of Errors
Special Reporting Situations
This is an incident where there are many
patients and injuries.
When there is not enough time to
complete the form before the next call, the
EMT-Basic will need to fill out the report
later
The local MCI plan should have some
means of recording important medical
information temporarily, e.g. triage tag,
that can be used later to complete the
form.
The standard for completing the form in an
MCI is not the same as for a typical call.
The local plan should have guidelines.
This is the only situation where a PCR may
not be fully completed.
MultipleCasualtyIncident(MCI)
MCI Triage Tags
Special Situation Reports
Used to document events that should be reported to local authorities, or to amplify and supplement primary report.
Should be submitted in timely manner.
Should be accurate and objective.
The EMT-Basic should keep a copy for his own records
The report, and copies, if appropriate, should be submitted to the authority described by local protocol.
Infectious disease exposure
Injuries to self/other providers
Hazardous areas/scenes
Social service referrals
Child/elder abuse
PCR Summation Reports
Continuous Quality Improvement
Information gathered from the pre-hospital care report can be used to analyze various aspects of the EMS System.
This information can then be used to improve different components of the system and prevent problems from occurring.