chapter 4 - long beach city...

Chapter 4

Documentation

Copyright ©2010 by Pearson Education, Inc. All rights reserved.

Prehospital Emergency Care, Ninth Edition Joseph J. Mistovich • Keith J. Karren

Objectives

1.  Define key terms introduced in this chapter. 2.  Describe each of the following purposes served by the

prehospital care report (PCR) (slides 12-22): a.  Continuity of patient care b.  Administrative uses c.  Legal document d.  Education and research e.  Evaluation and continuous quality improvement (CQI)

3.  Describe characteristics, including advantages and disadvantages, of both paper and computer-based (electronic) PCR formats (slides 23-24).

Objectives

4.  Explain the purposes of the U.S. Department of Transportation (DOT) minimum data set for PCRs (slide 26).

5.  List the elements of the DOT minimum data set for PCRs (slides 26-27).

6.  Describe the purpose and contents of each of the following sections of a PCR (slides 28-37): a.  Administrative data b.  Patient demographics and other patient data c.  Vital signs d.  Narrative e.  Treatment

Objectives

7.  Give examples of each of the following types of PCR narrative information (slides 34-35): a.  Chief complaint b.  Pertinent history c.  Subjective information d.  Objective information e.  Pertinent negatives

8.  Use common abbreviations and medical terminology accurately in PCRs (slides 63-64).

Objectives

9.  Explain each of the following legal concerns with respect to the PCR (slides 38-48): a.  Confidentiality b.  Allowed distribution of the PCR or information included in it c.  Documenting a patient’s refusal of treatment d.  Falsification of the PCR e.  Correction of errors

Objectives

10.  Discuss how to handle each of the following situations with respect to the PCR (slides 48-55): a.  Transfer of patient care when returning to service prior to

completing the PCR b.  Multiple-casualty incidents (MCIs) c.  Special reporting situations, such as infectious disease

exposure and suspicion of abuse or neglect

11.  Accurately and completely record pertinent patient and EMS call information using the SOAP, CHART, and CHEATED methods (slides 56-62).

Topics

"  Functions of the Prehospital Care Report "  Collection of Data in Prehospital Care Reports "  Legal Concerns "  Special Situations "  Alternative Documentation Methods "  Medical Abbreviations

Dispatch

EMS Unit 17

Respond to 57 Vallejo Road for a vehicle versus a parked car

Time out 1321

Upon Arrival

•  Female party who called 911 indicates the male who struck her vehicle was slumped over wheel

•  States now he seems okay •  As you approach a mid-30s male he states, “Great!

As if I didn’t have enough trouble today, I’ve got to deal with you guys! Go away. I don’t need any help!”

How would you proceed?

Back to Topics

Functions of the Prehospital Care

Report

Continuity of Medical Care

Back to Objectives

•  Provides a baseline for other providers •  Gives an understanding of events and

reasons for the call

Administrative Uses

•  Becomes part of patient record

•  Used for billing •  Statistics

Legal Document

•  Is legal document •  May appear as a witness •  Can be months or years later •  May be a defense

Educational and Resource Uses

•  Can look at positive or negative effects •  May identify training needs

Evaluation and Continuous Quality Improvement

•  Documentation part of quality improvement •  Medical oversight

Back to Topics

Collection of Data in Prehospital Care

Reports

PCR Formats

Back to Objectives

•  Written •  Computerized

PCR Data

The Minimum Data Set

Back to Objectives

•  Chief complaint •  Level of

responsiveness •  Blood pressure •  Skin color,

temperature, and condition

•  Pulse rate •  Respiratory rate and

effort •  Patient

demographics •  Times of the call

PCR Data

Administrative Information

Back to Objectives

EMS unit and run or call number

Names of crew and levels of certification

Address to which unit is dispatched

PCR Data

Patient Demographics and Other Patient Data

•  Legal name, age, sex, race, and birth date

•  Home address •  Location where

you found the patient

•  Insurance/billing •  Care rendered

prior to EMT arrival

PCR Data

Vital Signs

At least two sets should be taken prior to arrival.

PCR Data

Patient Narrative

Back to Objectives

•  Chief complaint

•  SAMPLE •  Objective data •  Subjective

data •  Pertinent

negatives

PCR Data

Treatment

•  Treatment •  Time •  Effect on patient

status

Back to Topics

Legal Concerns

Confidentiality

Back to Objectives

•  Information on PCR is confidential •  Be familiar with HIPAA

Distribution

•  Follow state rules and local protocol for PCR distribution

•  Leave a copy of PCR at receiving facility (© Ray Kemp/911 Imaging)

Refusal of Treatment

•  Document competency •  Document your efforts completely •  Have patient sign refusal •  Offer patient alternate methods of getting care •  Remind patient that EMS can always return

Falsification

•  Do not try to cover up mistakes •  Do not compromise patient care

Falsification

Correcting Errors

•  Draw single line, initial it, write the correct information beside it

•  Do not erase •  Do not write over

Back to Objectives

Back to Topics

Special Situations

Transfer of Care Report

•  Obtain a signature from the medical professional who is assuming care

•  Leave a copy of report with facility

Multiple-Casualty Incidents

•  Follow local MCI plan for record keeping

•  Use triage tags

(© Stephanie Ruet/Corbis Sygma)

Special Reports

•  Suspected abuse •  Exposures •  Injuries to EMS members •  Information for other agencies (© David Handschuh)

Back to Topics

Alternative Documentation

Methods

SOAP

Back to Objectives

•  S – Subjective •  O – Objective •  A – Assessment •  P – Plan

CHART

•  C – Chief complaint •  H – History •  A – Assessment •  R – Rx •  T – Transport

CHEATED

•  C – Chief complaint •  H – History •  E – Exam •  A – Assessment •  T – Treatment •  E – Evaluation •  D – Disposition

Back to Topics

Medical Abbreviations

Only use universally accepted medical abbreviations.

Examples: •  BP – Blood pressure •  bpm – beats per minute •  CVA – Cerebrovascular accident •  CHF – Congestive heart failure

Back to Objectives

Follow-Up

Assessment •  You notice he has a bruise above

left eye •  You are able to calm patient •  He refuses all assessment and

treatment

Documentation •  You note all pertinent findings •  Document refusal •  Have Mr. Makynen read and sign

refusal •  Suggest Mr. Makynen see a doctor

or call 911 if things change •  Now clear and in service

•  36-year-old female complaining of severe abdominal pain

•  The patient is alert and oriented Vital signs: •  BP: 88/64 mmHg •  HR: 128 bpm with weak radial pulses •  RR: 24 with adequate chest rise •  Skin is pale, cool, and clammy •  SpO2 is 96 percent on room air

Critical Thinking Scenario

SAMPLE history: •  S – Feels light-headed and dizzy every

time she stands up; she’s also nauseated •  A – No known allergies •  M – Over-the-counter Claritin for allergies •  P – No pertinent medical history; tonsils

removed when she was ten years old •  L – Nothing to eat or drink for seven hours •  E – Has “not felt real good” for a few days

Critical Thinking Scenario

Pain assessment: •  O – Pain began suddenly and has

progressively worsened; was sitting on the couch watching television when it began

•  P – Nothing makes it better or worse •  Q – Dull, aching, and intermittent •  R – Nonradiating •  S – Eight out of ten •  T – Four hours

Critical Thinking Scenario

Physical exam: •  Pupils are equal and sluggish to respond •  Breath sounds are equal and clear

bilaterally; no JVD •  Abdomen is rigid and tender; no evidence

of trauma to the abdomen •  Good motor and sensory function in all

four extremities; peripheral pulses are very weak

Critical Thinking Scenario

Repeat vital signs: •  BP: 82/62 mmHg •  HR: 134 bpm, radial pulses barely

palpable •  RR: 26 with adequate chest rise •  Skin is more pale, cool, and clammy •  Pulse oximeter reading “error”

Critical Thinking Scenario

•  En route to the hospital, the patient begins to close her eyes

•  You must verbally instruct her to open her eyes

•  For your PCR documentation: Jennifer Sampson 1321 Oakridge Drive Smithville, Ohio

Critical Thinking Scenario

1.  What can this information be used for? 2.  How will the medical personnel in the

medical facility use the information? 3.  What will your EMS use the information

for? 4.  What would you document in the patient

information section of the minimum data set?

Critical Thinking Questions

5.  What would you document in the administrative section of the PCR?

6.  What information would you write in the patient narrative section?

7.  Should any of the information not be reported in the PCR?

8.  If you were to make a mistake while writing the PCR, how would you correct it?

Critical Thinking Questions

9.  If the PCR contains a box for a third set of vital signs, what would you document in this patient?

10. How would you collect additional information needed for your PCR?

Critical Thinking Questions

Reinforce and Review

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