CHAPTER 14 Documentation “If it’s not written down, you didn’t do it!!!”

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.