Pt assess documentation

Documentation

Topics Principles and Purposes of

EMS Documentation Medical Terminology & Abbreviations Roles of Documentation Subjective & Objective

Documentation Evaluation of a Finished Document Special Situations

Introduction

Your written prehospital carereport (PCR) is the only truefactual record of events.

Your PCR is your solepermanent, complete writtenrecord of events during theambulance call.

Uses for PCR’s

Medical Administrative Research Legal

Run data in a PCR helps agencies to improve patient care.

Complete both the narrative and check-box sections of every PCR.

General Considerations

Use appropriate medicalterminology.

Use acceptable and approvedabbreviations and acronyms.

If you do not know how to spell a word, look it up or use another word…

Some systems use check boxes, some use bubble-sheets, and others use

electronic documentation

Times

Whenever possible, record alltimes from the same clock.

When that is not possible, besure that all the clocks andwatches you use aresynchronized.

Communications

The communications with thehospital are another important item to document.

Document ANY medical advice ororders you receive and the results of implementing that advice and those orders.

Pertinent Negatives

Document all findings of your assessment, even those that are normal.

Oral Statements

Whenever possible, quote the patient—or other source of information—directly.

Example: Bystanders state the patient was “acting bizarre and threatening to jump in front of the next passing car.”

Elements of Good Documentation

Accuracy Legibility Timeliness Absence of alterations Professionalism

The Proper Way to Correct a Prehospital Care Report

Professionalism

Never include slang, biasedstatements, or irrelevantopinions.

Include only objectiveinformation.

Always write and speak clearly.

2 Narrative Formats

CHART Chief complaint History Assessment Rx (treatment) Transport

SOAP Subjective Objective Assessment Plan

Narrative Writing

Subjective part of your narrativecomprises any information that youelicit during your patient’s history.

Objective part of your narrativeusually includes your generalimpression and any data that youderive through inspection, palpation, auscultation, percussion, anddiagnostic testing.

Special Considerations

Patient refusals Services not needed Mass casualty incidents

Patient Refusals

Patients retain the right to refusetreatment or transportation if theyare competent to make that decision.

Two main types of refusals: Person who is not seriously

injured and does not want to go to the hospital

The patient refuses even though you feel he needs it.

A patient’s refusal of care requires careful documentation.

One Example of a “Refusal of Care” Form

Services Not Needed

Some systems allow paramedics todetermine patients that do notrequire ambulance transportation.

While this may help to reduceambulance utilization, the risks ofdenying transport are even greaterthan those of a refusal.

Evaluate all patients with even minor injuries and document appropriately.

Mass Casualty Incidents

Multiple patients, mass casualties,and disasters all present specialdocumentation problems.

Weigh your patient’s needs againstthe demand for completedocumentation.

Follow local guidelines and utilizethe appropriate forms such as triage tags.

Triage tags are used to record vital information on each patient quickly.

Consequences of Inappropriate

Documentation Inappropriate documentation can

have both medical and legalconsequences. Do not guess about your patient’s

problems. Write neatly, clearly, and legibly. Complete your form completely. Spelling counts!

Summary Principles and Purposes of

EMS Documentation Medical Terminology & Abbreviations Roles of Documentation Subjective & Objective

Documentation Evaluation of a Finished Document Special Situations