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The Vermont Department of Health
Pre-Hospital Documentation
Vermont Emergency Medical Services
Last updated October 2006
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The Vermont Department of Health
An Actual Run Form
Upon our arrival, found pt in bed with first responders complaining of breathing difficulty. Pt. physician saw her yesterday. Had cold X 2 weeks. Physician said lungs were congested. Nauseated, no vomiting. Upon listening to lung, equal but noisy. Pt initially put on 4 liters nonrebreather, complained so we used 24% Venturi. Allergic codeine. Dr. Bitlett. Pt diabetic due for insulin 8:00. Meds insulin.
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The Vermont Department of Health
An Actual Run FormUpon our arrival, found pt in bed with first responders complaining of breathing difficulty. Pt. physician saw her yesterday. Had cold X 2 weeks. Physician said lungs were congested. Nauseated, no vomiting. Upon listening to lung, equal but noisy. Pt initially put on 4 liters nonrebreather, complained so we used 24% Venturi. Allergic codeine. Dr. Bitlett. Pt diabetic due for insulin 8:00. Meds insulin.
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The Vermont Department of Health
Session Goal
At the end of this session, the student will be able to use the Vermont EMS Incident Report Form to document a pre‑hospital call in a systematic and complete fashion.
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The Vermont Department of Health
Learning Objectives
At the end of this session, the student will be able to:
1. describe the SOAP or CHART method of charting 2. list at two principles of writing a narrative
3. describe the role of documentation when a patient refuses care or transport
4. describe how care administered to a patient in a multiple casualty incident is documented
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The Vermont Department of Health
Learning Objectives
5. given pieces of information (in random order) about a call, properly document the assessment and treatment of the patient
6. describe the procedure to use when adding or correcting information on the run report form after the copies have been separated
7. (for Advanced EMTs only) list the pieces of information which should be recorded on the run report form when the EMT administers advanced life support in the field.
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The Vermont Department of Health
What This Session Will Cover
Importance & Purposes of Documentation
Frequent Problems (and Solutions)
Completing the VT EMS Incident Report Form
Exceptions and Special Cases Demonstration and Practice
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The Vermont Department of Health
Purposes of Documentation
educational • properly done within HIPAA
requirements
administrative• statistics and billing
research
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The Vermont Department of Health
Purposes of Documentation
evaluation and critique• What proportion of patients with a
chief complaint of difficulty breathing receive high concentration oxygen?
continuity of treatment in hospital
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The Vermont Department of Health
Purposes of Documentation
legal• form is not evidence in itself• becomes evidence as part of testimony of
witness to authenticate it • can be used to refresh the memory of a
witness• retain original for legal purposes
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The Vermont Department of Health
Kinds of Errors
incomplete or incorrect blanks and boxes (e.g., date)
SOLUTION? have someone else check the form
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The Vermont Department of Health
Kinds of Errors
incomplete or incorrect narrative (e.g., description of a patient's injuries without mentioning that he was in a collision
SOLUTION? use an outline to remind yourself what information
to include
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The Vermont Department of Health
Kinds of Errors
form reflects incomplete assessment or poor care
SOLUTION? document extenuating circumstances
combative patient language barrier pt refusal to cooperate extrication difficulties delay in response, at the scene, or en route to ED
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The Vermont Department of Health
Kinds of Errors
form reflects incomplete assessment or poor care
SOLUTION? if deviation from the usual treatment protocols
occurred, explain why; do not try to cover up errors or omissions in care
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The Vermont Department of Health
The Vermont EMS Incident Report Form
or Patient Care Report (PCR)
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The Vermont Department of Health
PCR Demographic Info
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The Vermont Department of Health
Code 2/Code 3
Any use of lights OR siren = Code 3
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The Vermont Department of Health
Nature of Call/CC
Fill in the chief complaint or nature of call as found, not as dispatched
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The Vermont Department of Health
Treatment & Vital Signs
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The Vermont Department of Health
Level of Treatment & Transport
Fill in treatment based on what the agency completing the form did for the pt
Fill in transport based on treatment the pt is receiving, regardless of who gives it
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The Vermont Department of Health
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The Vermont Department of Health
Trauma Score
Complete for trauma patients only
Use information from earliest EMS assessment
Let the hospital worry about adding up the numbers
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The Vermont Department of Health
Vital Signs
Repeat VS frequently Put SpO2, blood glucose, etc. in comments
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The Vermont Department of Health
Vital Signs
As needed, draw lines to make additional boxes for vital signs
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The Vermont Department of Health
A System for Comments
S
O
A
P
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The Vermont Department of Health
The SOAP System
Subjective
Objective
Assessment
Plan
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The Vermont Department of Health
Another System for Comments
C
HART
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The Vermont Department of Health
The CHART System
Chief complaint
HistoryAssessmentRx (treatment)Transport
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The Vermont Department of Health
SOAP
Subjective• Chief Complaint (CC)• History of Present Illness (HPI)• Past Medical History (PMH)
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The Vermont Department of Health
Subjective/History
History of Present Illness (HPI)• O• P• Q• R• S• T• U
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The Vermont Department of Health
Subjective/History
History of Present Illness (HPI)• Onset• Provokes• Quality/Quantity• Region/Radiates• Severity• Time• Undo+ associated symptoms
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The Vermont Department of Health
Subjective/History
Past Medical History (PMH)• M A• A M• I P• D L• S E
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The Vermont Department of Health
Subjective/History
Past Medical History (PMH)• Medications Allergies• Allergies Medications• Illnesses Pertinent past history• Doctor Last oral intake• Surgery Events leading to illness
or injury
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The Vermont Department of Health
Objective/Assessment – Trauma
pt appearance, position and surroundings head, eyes, ears, nose, throat neck chest abdomen and pelvis extremities
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The Vermont Department of Health
Objective/Assessment - Cardiorespiratory
pt appearance, position and surroundings neck – jugular veins chest – lung sounds extremities – pedal edema other – oxygen saturation, EKG as
appropriate
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The Vermont Department of Health
Objective/Assessment – Altered Mental Status
pt appearance, position and surroundings mental status• AVPU• orientation• memory• loss of consciousness
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The Vermont Department of Health
Objective/Assessment – Altered Mental Status
pupils trauma exam, including movement of
extremities other • blood glucose• oxygen saturation, EKG as appropriate
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The Vermont Department of Health
Exercise #1
In the first blank for each phrase, indicate what kind of information is given by using Hx for history and PE for physical exam.
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The Vermont Department of Health
Principles of Narrative Comments
Include pertinent negatives.• If a pt c/o chest pain, document the presence or
absence of .
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The Vermont Department of Health
Principles of Narrative Comments
Include pertinent negatives.• If a pt c/o chest pain, document the presence or
absence of difficulty breathing.
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The Vermont Department of Health
Principles of Narrative Comments
Include pertinent negatives.• If a pt c/o chest pain, document the presence or
absence of difficulty breathing.• If a pt c/o a blow to the head, document whether
or not the pt .
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The Vermont Department of Health
Principles of Narrative Comments
Include pertinent negatives.• If a pt c/o chest pain, document the presence or
absence of difficulty breathing.• If a pt c/o a blow to the head, document whether
or not the pt lost consciousness.
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The Vermont Department of Health
Principles of Narrative Comments
Describe, don’t conclude.• “A well known, unshaved, unkempt, foul-smelling,
slightly cyanotic, 62 y/o alcoholic gentleman was carried into our emergency room by three million lice, all screaming, ‘Please save our host.’”
- from an actual doctor’s note shown to a jury in a malpractice suit in 1977
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The Vermont Department of Health
Principles of Narrative Comments
Describe, don’t conclude.• Pt had slurred speech, frequent mood swings
between happy and combative, inability to walk without assistance and odor of alcoholic beverage on his breath.
• Is there any need to say this pt was drunk?
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The Vermont Department of Health
Principles of Narrative Comments
Record important observations about the scene.• Suicide note found next to pt
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The Vermont Department of Health
Principles of Narrative Comments
Avoid radio codes on the form.Code 11, 33, 55, 77
In the 1970s in some parts of Vermont, this meant:
Code 11 = emotional disturbance
Code 33 = overdose
Code 55 = alcohol intoxication
Code 77 = attempted suicide
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The Vermont Department of Health
Principles of Narrative Comments
Use only standard abbreviations.• NOT, for instance
CTD
(circling the drain) HIBGIA
(had it before, got it again) FTD
(fixing to die)
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The Vermont Department of Health
Principles of Narrative Comments
Include changes in the patient’s condition after treatment or while en route.• After 1 tube of oral glucose, pt became lucid and
thanked us profusely.
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The Vermont Department of Health
Principles of Narrative Comments
Identify the source of information when it is not the patient.• Per wife, pt has used cocaine for 2 years.
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The Vermont Department of Health
Spelling
medication names
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The Vermont Department of Health
Spelling
orient
orientate X
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The Vermont Department of Health
Spelling
clavicle
clavical
X
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The Vermont Department of Health
Spelling
dilated
dialated
X
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The Vermont Department of Health
Spelling
crepitus
crepidusX
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The Vermont Department of Health
Spelling
prostate
prostrate
X
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The Vermont Department of Health
Spelling
palpitation
palpation
X
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The Vermont Department of Health
Spelling
seize
seizure
(verb)
(noun)
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The Vermont Department of Health
Spelling
diaphoretic
sweaty
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The Vermont Department of Health
Punctuation
Who says punctuation doesn’t count?
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The Vermont Department of Health
Punctuation
Pt experiences difficulty swallowing tires easily.
OR Pt experiences difficulty swallowing, tires
easily.
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The Vermont Department of Health
Punctuation
She moves her bowels roughly, three times a day.
ORShe moves her bowels roughly three times a
day.
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The Vermont Department of Health
Confidentiality
Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule• It’s not just the form that’s confidential, but the
medical information about the patient.• HIPAA applies whenever your service bills a pt.• Even if a pt doesn’t get a bill, the EMS agency and
providers are expected to maintain confidentiality.
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The Vermont Department of Health
Exceptions and Special Cases
Multiple Casualty Incidents Refusal of Care
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The Vermont Department of Health
Multiple Casualty Incidents
Use Met-Tags or local approved equivalent
Standard of care for documentation is different in an MCI
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The Vermont Department of Health
MCI
In an MCI, fill out tag as completely as circumstances allowAfterward, use tag to complete PCR the best you can
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The Vermont Department of Health
Refusal of Care
Vermont Supplemental Report for Patient Non-Transports• to be used with non-
transport protocol• to be completed in
addition to PCR• available free from EMS
Office
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The Vermont Department of Health
Refusal of Care
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The Vermont Department of Health
Refusal of Care
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The Vermont Department of Health
Refusal of Care
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The Vermont Department of Health
Refusal of Care
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The Vermont Department of Health
Refusal of Care
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The Vermont Department of Health
What About Other VT EMS Forms?
VT EMS no longer collects • Cardiac Arrest Report Forms or • Esophageal Tracheal Combitube Forms
Follow district medical advisor’s directions Both forms are available free of charge from
VT EMS Office
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The Vermont Department of Health
Learning from Others’ Experience
Evaluate the following narratives and describe how they could be improved.
Note: Information has been typed for ease of reading, but these are actual forms.
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The Vermont Department of Health
Example # 1
Pt has not been feeling well X 1 day. At 4:00 am this date pt started vomiting and uncontrollable bowels. Aching in both arms & shoulders. Pt had a temp. of 39.1 at this time. Pt has taken Datril one at 0116 and again at 0430 this am. No meds. No doctor. No allergies
942 88 98/60 20
1009 124 80/Dopp 17
(20 y/o female)
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The Vermont Department of Health
Example # 1
Strengths?• two complete sets of VS
en route to hospital
Improvements?• disorganized• skimpy (what was the
chief complaint?)• recognize and treat
shock when your patient has it
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The Vermont Department of Health
Example # 2
R compound open femur fracture. Lacerations – inner R thigh, R ankle, R toes, R little toe underneath. Abrasions – both elbows, 4 burn marks 1 ½” diameter in thoracic/lumbar region of back. femur fracture w/ bone coming thru medial aspect approx 3” above knee. Open wound approx 3” long lateral aspect approx 2” above knee 1 open wound with great deal of bleeding from medial aspect of wound. Contusions & lacerations to tib/fib area of R leg. Pt. has good motor function of the toes on the R leg and good distal pulse. Pt drowsy and difficult time getting radial pulse. Pt had no guarding in abdomen breath sounds good. NKA, NKM. Pt took off helmet and jacket prior to arrival.
1450 R/L KVO 16 ga LAB
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The Vermont Department of Health
Vital Signs – Example # 2
1427 56 84/P 80Both legs of MAST inflated
1450 68 104/D
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The Vermont Department of Health
Example # 2
Strengths?• detailed descriptions of
injuries• recognized and treated
shock
Improvements?• What happened (how
was pt injured)?• Pre-MAST vital signs?• Was initial respiratory
rate really 80 per minute?
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The Vermont Department of Health
Example # 3
68 y/o male found lying face down on bedroom floor, had vomited. Pt responsive to verbal stimuli, could answer questions with single words, but could not tell us what happened or speak understandably. Able to move all extremities, oriented to person only. Large contusion L forehead, small abrasion on R forehead and upper bridge of nose. Pupils constricted. Wife reports hx stomach problems but was very upset, unable to give good history.
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The Vermont Department of Health
Example # 3
Strengths?• good description of
abnormal mental status• good explanation for lack
of history
Improvements?
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The Vermont Department of Health
Example #4
Arrived to find alert oriented X 3 28 y/o female c/o substernal pain that started approx 4 hrs ago and has been constant. Pain radiated into back. Skin warm, dry & pink. Pain felt as something heavy. Lungs clear & equal bilaterally. Had stress test earlier today – results unknown. Transported with 10 lpm NRB in Fowler’s position. M: Axid. A: N/A. I: Mitral valve prolapse. D: McDonald. S: 1988
Hysterectomy.2000 108 128/96
24
2018 112 130/P 28
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The Vermont Department of Health
Example # 4
Strengths?• good description of
history of present illness• two complete sets of vital
signs
Improvements?• nonstandard
abbreviations
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The Vermont Department of Health
Correcting Information
Before form submitted:• if small error, draw single line through it and initial
it• agency may require date and time, too• if large error, start new PCR
Do NOT try to obliterate error• appears EMT was trying to hide something
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The Vermont Department of Health
Correcting Information
After form submitted:• if information important, EMT who wrote PCR
should use separate piece of paper to: note reason for addendum and why it was not in original
report note date and time of addendum describe additional or corrected information
• Attach to PCR• On original form, write “See addendum”
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The Vermont Department of Health
IV Fluids & Medications
When a slash separates two words in a box, the word to the left of the slash is for IV fluids and the word to the right is for medications.
IV fluids
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The Vermont Department of Health
IV Fluids & Medications
When a slash separates two words in a box, the word to the left of the slash is for IV fluids and the word to the right is for medications.
Medications
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The Vermont Department of Health
IV Fluids & Medications
Remember to extend the box lines before writing your narrative.
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The Vermont Department of Health
Exercise #2
Work in small groups and organize the information on the cards so that it fits the SOAP or CHART format.
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The Vermont Department of Health
Summary
Have a system for completing the PCR Have someone else check the form Beware spelling and punctuation pitfalls Use non-transport form when appropriate
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The Vermont Department of Health