charting. the patient and family the average person has contact with 9-1-1 twice in their lifetime...
Post on 22-Dec-2015
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The Patient and Family
• The average person has contact with 9-1-1 twice in their lifetime
• Is it an emergency or not?
Radio report should include• Unit calling• Pt age and gender• Name of primary physician• Chief complaint• General condition• Pertinent history• Management• ETA
Report at ED bedside
• Introduce pt.
• Use same logical format
• Include pertinent negatives and
positives
• Include information about allergies
and meds
The written record
• A story– Logical beginning– Logical ending– Bulk of the material in the middle
• Report must be:– Complete – Accurate– Legible– Left at hospital before clearing call
Written record, cont.
• Must be signed by both PIC and
partner
• Limit statements to the facts.
• No assumptions or judgments
Charting, cont.
• DON’T make discriminatory statements
• Don’t swear on charts– “get the H**l out of my house”
• Use quotations
• Do use accepted abbreviations
• Draw single line through errors and initial them
Pearls for charting
• Don’t let your paperwork interfere with patient care
• If information is not recorded, it was NOT DONE.
• If you didn’t do it, don’t write it down• Don’t document opinions• If you forgot it, don’t forget it next time• If you ever need it, this is your only
defense
Charting formats
• Flow chart
– Fills out the story
– Must include baseline vitals, as well
as at least one other set
– Document times
SOAP format
• Subjective– Beginning of story
• Objective– Middle – most difficult part– Document head to toe– General assessment vs focused
assessment
SOAP format, cont.
• Assessment– Or R/O; what do you think is wrong?
• Plan– What did you do to fix the problem?– What response did the patient have to
your tx?– How was the patient physically
transferred?– Bed rails up or down?– Whose care did you leave pt in?
Did you?
• Record all information needed by others?
• Adequately state all your observations about pt.?
• Support your clinical impression?• List all care given to pt?• Use only recognized abbreviations?• And your partner sign the form?
And finally…
• Is your information complete
enough so that you could
reconstruct the entire situation and
defend your actions later if
necessary?
Refusals
• Decision-making capacity– The ability to make an informed
decision
• Impaired decision making capacity– The inability to understand the nature
of illness or injury, and the risks and consequences of refusing care
Impaired decision making capacity (IDMC)• Alcohol ingestion• Use of drugs• Altered mentation from any medical
condition or trauma
• Don’t use “competent” or
incompetent”
IDMC
• Don’t have impaired person sign refusal form
• Treat and transport any person who is impaired
Documenting refusals• General appearance• Vitals• H & P• Mental status• Presence of drugs or alcohol• Assessment of decision making capacity• Risks explained and advice offered• Response to efforts by EMTs to provide
care• Communications with law enforcement,
family, OLMC, pt.
Patient refusal definitions
• 18 y/o or older• No significant mechanism of injury• No significant signs of trauma• No acute medical condition• No behavioral conditions• No comorbid factors