Documentation /Charting Don Hudson, D.O.,FACEP/ACOEP

Documentation Documentation /Charting/Charting

Don Hudson, D.O.,FACEP/ACOEP

DocumentationDocumentation

Purposes–Preserves basic patient information

–Records changes in patient condition

–Justifies treatment

–Allows continuity of care

–Satisfies regulatory requirements

–Provides data for quality control


Protection for EMS personnel Reflection of good patient care


An accurate, complete, legible medical record implies

accurate, complete, organized assessment and management


Characteristics of good medical record–Accurate

–Complete

–Legible

–Free of extraneous information

AccurateAccurate

Document facts, observations only Do NOT speculate about patient or

incident Double-check numerical entries Recheck spellings of:

–Persons

–Locations

–Medical terms

AccurateAccurate

If you make a mistake, document it.

It is better to record your own mistakes that for someone else to uncover them.

CompleteComplete

Include all requested information If information requested does not apply,

note “not applicable” or “N/A” Include at least two sets of vital signs on

every patient Failure to document implies failure to

consider If you look for something and it isn’t there,

document its absence

CompleteComplete

IF IT ISN’T DOCUMENTED, IT WASN’T

DONE!

LegibleLegible

If you cannot read the report, you may be unable to determine what happened

Documents presented in court must “speak for themselves”

If a document cannot be deciphered, the jury has to right to ignore it altogether

LegibleLegible

If the report is sloppy, others will assume that the care was

equally sloppy

Free of Extraneous Free of Extraneous InformationInformation

Avoid labeling patients (“drunk”, “psych patient”)

Describe the observations you made Preface comments made by the patient

with “per the patient” or “patient stated”


Record hearsay only if applicable Do NOT record hearsay as facts Use quotation marks only if a statement is

accurate word-for-word


Avoid interjecting humor

The public does not regard EMS as a funny business


A copy of the report must be left with the patient at the receiving hospital–State law requires this

–Patient care has not legally been transferred until the receiving facility has your written report


The person who rode with the patient writes the report

All personnel who participated in care should review the report

DocumentationDocumentation If something needs to be corrected,

correct it The sooner an error is corrected, the

more credible and reliable the change is

Mark through information so it is still readable

Then write in the new information and initial/date the change


If you have a long report, don’t hesitate to use additional pages


Avoid stating diagnostic impressions Report facts and observations If you must state a diagnostic impression

– Do so within the scope of your training

– Include the observations that led to the impression


Avoid using “possible” or “?” when the observation would have been

obvious to anyone


Be sure treatments recorded match the mechanism of injury or the diagnostic impression

If something should have been done that was not, state why


If spaces are provided for documenting times, fill them in carefully

Failing to document times implies lack of concern about the time factor

If you have a prolonged scene time, say why


If you put a monitor on the patient, a hard copy of the EKG should

accompany the report


If a patient complains of pain in a area, state what you found when you examined the area

Failure to record your observations implies that you noted the complaint, but did not investigate it


On MVCs, report –Type of collision (head-on, roll-over,

lateral impact, etc.)

–Degree of damage to vehicles

–Location of patients

–Use of seatbelts


On falls report:–Where the patient fell from

–How far the patient fell

–The surface the patient fell onto

–Why the patient probably fell


On head injuries report:–Level of consciousness

–Pupillary responses


On head injuries report:–Presence/absence of:

» Discharge from nose and ears

» Cervical pain, muscle spasm, tenderness, deformity

» Paresthesias

» Altered motor function

» Altered sensory function


On chest injuries report:–Position of trachea

–Status of neck veins, breath sounds, heart sounds

–Presence or absence of» Crepitus

» Subcutaneous air

» Paradoxical movement of chest wall


On extremity injuries report:–Distal skin color and temperature

–Presence or absence of:» Distal pulses

» Motor function

» Sensory function

Good Documentation is NOT Good Documentation is NOT C.Y.AC.Y.A

Good Documentation is a Reflection of Good Patient

Care