Chapter 20 Record. © 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 2 Overview The Record Principles of Documentation

Chapter 20Record

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© 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved

Overview

The Record Principles of Documentation Special Incident Reports The EMT as a Good Citizen Multiple-Casualty Incident Patient Refusal Documentation

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The Record

Problem-Oriented Medical Record Keeping (POMR) – Universal standard of documentation– Uses a problem or diagnosis as an index– Patient’s chief complaint is basis for EMT care

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The Record

Functions of the record– Prehospital PCR– Can speak for the patient– Can describe scene where patient was found

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The Record

Functions of the record: Quality improvement – Administrative purposes tied to patient care

• Continuous quality improvement process

• Peer review process

• Call review process

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The Record

Functions of the record: Research– Used to improve EMT practice

• Identifies what works and what does not work • Helps identify ineffective treatments• Helps underpin particular practice• Suggests ways to improve care

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The Record

Functions of the record: Administrative purposes – Not directly tied to patient’s care

• Billing information• Information for other reports

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The Record

Functions of the record: Legal document– Used in court of law– EMT must depend on PCR when testifying

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The Record

Minimum data sets– Administrative data set– Medical data set– State and federal governments

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The Record

Format for documentation: – Open format– Closed format– Hybrid format

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The Record

Format for documentation: SOAP chartingS = Subjective

O = Objective

A = Assessment

P = Plan

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The Record

Format for documentation: Extended charting methods– SOAPIE – CHART

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The Record

Format for documentation: CHEATED chartingC = Chief complaintH = HistoryE = ExaminationA = AssessmentT = Treatment E = EvaluationD = Disposition

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Stop and Review

List four functions of the PCR. List the elements of the acronym CHEATED.

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Principles of Documentation

Be objective Document only patient statements that clarify

condition Document all care Be timely Complete PCRs at point of transfer

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Documentation standards– The record must be readable– Use accurate abbreviations if used at all

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Documentation standards: Errors and corrections– Cross-outs– Do not use white correction fluid or black out– Initial last point– Add initials, date, and time to end of PCR– Documentation can be reopened when needed

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Documentation standards: Legibility– Write clearly– May use block printing– Use black ink

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Special Incident Reports

Special incident report—for documentation of specific incidents– Injury to EMT– Infectious disease exposure– Equipment failure

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Special Incident Report

Injury to EMT– Report injury immediately– Report serves as a basis for claim

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Infectious disease exposure– Report EMT exposure– Give report to infection control officer– OSHA regulation– Follow local protocols

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Equipment failure– File report when equipment fails on a call– Return report to a supervisor– Reports may be legal evidence

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The EMT as Good Citizen

Patient care is always the EMT’s first responsibility

Other responsibilities Report suspected abuse Written testimony (affidavit) Testifying in court Agency procedure

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Multiple-Casualty Incident

Half a dozen to a hundred or more patients Triage tags

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Patient Refusal Documentation

When patient refuses care – Document his decision-making– Patient refusal form– Consult EMS supervisor– Contact ED physician– Witness– Standardized refusal of medical assistance

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Stop and Review

Describe how to correct an error in the record.

List several reasons to write a special incident report.

Documents

Chapter 20 Record. © 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 2 Overview The Record Principles of Documentation