A patient suffers a diabetic emergency She is treated by the local EMS crew with an A patient suffers a diabetic emergency She is treated by the local EMS crew with an IV an ampule of D50 and transported to the closet hospital despite family members IV an ampule of D50 and transported to the closet hospital despite family members telling you that the patient does not go theretelling you that the patient does not go there

Transport is uneventful and care is turned over to the ED Nurse with a quick verbal Transport is uneventful and care is turned over to the ED Nurse with a quick verbal reportreport

An hour later a private ambulance is called to transport the patient to her desired An hour later a private ambulance is called to transport the patient to her desired hospital for definitive care They notice the IV has infiltrated and D50 got into her hospital for definitive care They notice the IV has infiltrated and D50 got into her surrounding tissuessurrounding tissues

The patient suffers significant tissue damage which requires a fasciotomy to The patient suffers significant tissue damage which requires a fasciotomy to decompress her hand and forearm She has permanent nerve damage and requires decompress her hand and forearm She has permanent nerve damage and requires skin graftingskin grafting

Who get invited to the lawsuit partyWho get invited to the lawsuit party

Depends on the documentation from everyone Depends on the documentation from everyone involved in patient careinvolved in patient care

DocumentationDocumentation

ldquoldquoIf you didnrsquot write it on your patient If you didnrsquot write it on your patient care report you didnrsquot do itrdquocare report you didnrsquot do itrdquo

ObjectivesObjectives Importance of DocumentationImportance of Documentation Identify Data on the PCRIdentify Data on the PCR Types of Documentation FormatsTypes of Documentation Formats Consequences for Poor DocumentationConsequences for Poor Documentation Special ConsiderationsSpecial Considerations Grammar and PunctuationsGrammar and Punctuations Electronic Reporting and WARDSElectronic Reporting and WARDS

Why so ImportantWhy so Important

Permanent part of Permanent part of the patients the patients medical recordmedical record

Written Proof that Written Proof that you did somethingyou did something

Written TestimonyWritten Testimony Quality Assurance Quality Assurance Operations Operations ResearchResearch

ldquoThe content and completeness of the pre-hospital care report directly affects the lawyerrsquos impression of the incident and influences his decision of whether or not to file a lawsuitrdquo

Richard A Lazar JD

Elements of the PCRElements of the PCR Date of the RunDate of the Run Type of callType of call TIMESTIMES

ReceivedReceived EnrouteEnroute SceneScene Patient ContactPatient Contact TransportTransport DestinationDestination

Medical HistoryMedical History AllergiesAllergies MedicationsMedications Chief ComplaintChief Complaint Trauma Trauma

MechanismMechanism Safety Safety

EquipmentEquipment

Vital signsVital signs Blood Blood

PressurePressure PulsePulse RespirationsRespirations Lung SoundsLung Sounds Cap refillCap refill Blood Blood

GlucoseGlucose PupilsPupils

OrganizationOrganization

S O A PS O A P CHARTCHART CHRONOLOGICAL CHRONOLOGICAL

SOAPSOAP

What happenedWhat happened What did you What did you

findfind What do you What do you

thinkthink What did you doWhat did you do

(S) (Subjective) What happened(S) (Subjective) What happened

Medic 27 responded emergent on a 39 year old female who had a syncope from the standing position Patient reports that she

was at a party when she began to feel nauseous Walked into back room and then

passed out on floor Witnesses report patient slumped forward on to a couch and then slid

backward to a carpeted floor Patient also reports that she recalls waking up on floor feeling cold and shivering Patient moved to bed with assistance A bystander called 911

for assistance

(O) (Objective) What did you find(O) (Objective) What did you find

Upon initial contact patient laying in bed in Upon initial contact patient laying in bed in bedroom Alert and oriented to name place bedroom Alert and oriented to name place

time and event Skin warm and dry with time and event Skin warm and dry with normal color and tone Mild muscle tremors normal color and tone Mild muscle tremors

(shivers) in arms and legs Patient does (shivers) in arms and legs Patient does report feeling cold Head normocephalic report feeling cold Head normocephalic without abnormality on visualization or without abnormality on visualization or

palpation Neck midline and intact without palpation Neck midline and intact without pain on palpation or movement Thoracic pain on palpation or movement Thoracic

lumbar and sacral spine intact without pain lumbar and sacral spine intact without pain on palpation or spontaneous movementon palpation or spontaneous movement

My WayMy Way

Level of ConsciousnessLevel of Consciousness Airway Breathing CirculationAirway Breathing Circulation Skin color and tempSkin color and temp Head to Toe ExamHead to Toe Exam Pertinent NegativePertinent Negative

(A) Assessment (What do you think)(A) Assessment (What do you think)

Patient transported to Hospital with seizure Patient transported to Hospital with seizure like activitylike activity

Not a diagnosisNot a diagnosis

Protocol FollowedProtocol Followed

(P) Plan What did you do(P) Plan What did you do

Patient transported non-emergent to Aurora Patient transported non-emergent to Aurora Medical Center emergency room Patient Medical Center emergency room Patient transported without change in status or transported without change in status or

level of consciousness Patients treatment level of consciousness Patients treatment plan included full secondary assessment plan included full secondary assessment detailed neurological examination vital detailed neurological examination vital

signs cardiac monitoring pulse oximetry signs cardiac monitoring pulse oximetry and supplemental oxygen Following hand and supplemental oxygen Following hand off report to staff patient left in hospital off report to staff patient left in hospital bed with rails up and staff in attendancebed with rails up and staff in attendance

C H A R TC H A R T

Chief ComplaintChief Complaint HistoryHistory AllergiesAllergies Rx-TreatmentRx-Treatment TransportTransport

(C) Chief Complaint(C) Chief Complaint

Medic 27 responded emergent on a 39 year old female who had a syncope from the standing position

(H) History Present Illness(H) History Present Illness

HPI (history of present illnessinjury) PMH (past medical history) PQRST AMPLE MOI Onset Signs and Symptoms

(A) Assessment(A) Assessment

Include both negative and positive findings Responses the patient has to your

assessment such as the presence or lack of pain andor the presence or lack of sensation

Diagnostic Testing ECG Pulse Oximetry Capnography Blood Glucose Monitoring

(R) Rx-Treatment(R) Rx-Treatment

Document your treatmentDocument your treatment Responses from the Patient to RxResponses from the Patient to Rx Changes in Patients conditionChanges in Patients condition

Example Example ldquoPain decreased to 510 from ldquoPain decreased to 510 from 710 after NTG administered710 after NTG administered

(T) Transport(T) Transport

Where did you goWhere did you go Change in condition during Change in condition during

transporttransport Alteration from ProtocolAlteration from Protocol Who did you turn care over to Who did you turn care over to

(Name if Possible) Ie RN Robinson(Name if Possible) Ie RN Robinson Patency of airway and IV fluidsPatency of airway and IV fluids

CHRONOLOGICALCHRONOLOGICAL

ldquoldquoWrite like your brain thinks itrdquoWrite like your brain thinks itrdquo

Dispatched non-emergent to University Hospitals Dispatched non-emergent to University Hospitals Emergency Educations center for a transport to Emergency Educations center for a transport to UW ER Arrived on floor and met by staff who UW ER Arrived on floor and met by staff who advised us that the patient was suffering from advised us that the patient was suffering from severe PES (Paramedic Education Syndrome) severe PES (Paramedic Education Syndrome) Patient is Mr D a 48 yo male with hx of PES and Patient is Mr D a 48 yo male with hx of PES and CHF who presented with chest pain and CHF who presented with chest pain and dyspneahellipdyspneahellip

Errors and FalsificationsErrors and Falsifications

Avoid ErrorsAvoid Errors Admit when you made a mistakeAdmit when you made a mistake

Revise if necessaryRevise if necessary Note date and time of revisionNote date and time of revision Keep original documentKeep original document Include purpose of the revisionInclude purpose of the revision Only the original author can make the Only the original author can make the

correctioncorrection

Errors and FalsificationsErrors and Falsifications

Always be honest and through in your Always be honest and through in your documentationdocumentation

CorrectionsCorrections Add a supplement on electronic reportsAdd a supplement on electronic reports One line across the error initial the One line across the error initial the

mistake and make the corrections on mistake and make the corrections on written reportswritten reports

Complete reports as soon as possible Complete reports as soon as possible Lost reports have HUGE legal implicationsLost reports have HUGE legal implications Dont keep copies of your reportsDont keep copies of your reports

HIPPAHIPPA

What Happens on What Happens on the Ambulance the Ambulance stays on the stays on the ambulance ambulance

Health Health InsuranceInsurance PortabilityPortability PrivacyPrivacy AccountabilityAccountability

HIPPAHIPPA

Protects the security and privacy of Protects the security and privacy of all medical records and other health all medical records and other health information used or shared in any information used or shared in any formform

Protects patients rights by giving Protects patients rights by giving access to health information and access to health information and control over how it is usedcontrol over how it is used

PHIPHI Protected Heath InformationProtected Heath Information

Information that relates toInformation that relates to The health of an individualThe health of an individual Health care provided to that individualHealth care provided to that individual Payment of heath care providedPayment of heath care provided

What can be sharedWhat can be shared

Health Insurance Company my need Health Insurance Company my need information to process a claiminformation to process a claim

Caregivers involved with direct care Caregivers involved with direct care Quality Assurance when necessaryQuality Assurance when necessary

Special ConsiderationsSpecial Considerations

Exposure and InjuryExposure and Injury Mass CasualtyMass Casualty Interfacility TransportsInterfacility Transports RefusalsRefusals

Mass Casualty EventsMass Casualty Events

Documentation may have to be Documentation may have to be postponedpostponed

Follow Local Policy and ProcedureFollow Local Policy and Procedure Comprehensive run report must be Comprehensive run report must be

completed for each patient when completed for each patient when time permitstime permits

Refusal of CareRefusal of Care

Potential for LiabilityPotential for Liability Good DocumentationGood Documentation Make it clearMake it clear

Refusal of CareRefusal of Care

The litigation rate for EMS has been steadily increasing

1048657 According to one study patients evaluatedby paramedics but not transported to thehospital account for 50 to 90 of EMSlawsuitsrdquo

1048657 Documentation is your best defenserdquo

DocumentationDocumentation

Physical FindingsPhysical Findings The advice you give the patient about The advice you give the patient about

being transported and the associated being transported and the associated risks for not being transportedrisks for not being transported

Clinical indications that patient is Clinical indications that patient is competent to make a rational decisioncompetent to make a rational decision

Signatures of the patient and witnessSignatures of the patient and witness Full narrativeFull narrative Advise to call 911 if condition changesAdvise to call 911 if condition changes

Do not at any time attempt to talk the patient out of going to the hospital

If you feel strongly that the patient should be seen make every attempt to convince them they should be seen

Donrsquot say lsquo I agree you donrsquot need to gordquo even if you agree

What not to sayWhat not to say

A patient suffers a diabetic emergency She is treated by the local EMS crew with an A patient suffers a diabetic emergency She is treated by the local EMS crew with an IV an ampule of D50 and transported to the closet hospital despite family members IV an ampule of D50 and transported to the closet hospital despite family members telling you that the patient does not go theretelling you that the patient does not go there

Transport is uneventful and care is turned over to the ED Nurse with a quick verbal Transport is uneventful and care is turned over to the ED Nurse with a quick verbal reportreport

An hour later a private ambulance is called to transport the patient to her desired An hour later a private ambulance is called to transport the patient to her desired hospital for definitive care They notice the IV has infiltrated and D50 got into her hospital for definitive care They notice the IV has infiltrated and D50 got into her surrounding tissuessurrounding tissues

The patient suffers significant tissue damage which requires a fasciotomy to The patient suffers significant tissue damage which requires a fasciotomy to decompress her hand and forearm She has permanent nerve damage and requires decompress her hand and forearm She has permanent nerve damage and requires skin graftingskin grafting

Initial Transport Agency-CFDInitial Transport Agency-CFD

First Receiving Hospital-St Anthony HospitalFirst Receiving Hospital-St Anthony Hospital

Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998

Lets Finish upLets Finish up

Be ProfessionalBe Professional AccurateAccurate ConsistentConsistent ThroughThrough ClearClear BriefBrief Paint the PicturePaint the Picture CollaborativeCollaborative

Legible spelling Legible spelling correctcorrect

Tell the TruthTell the Truth Donrsquot duplicate infoDonrsquot duplicate info Follow ProtocolsFollow Protocols Plain LanguagePlain Language Relevant InformationRelevant Information ldquoldquoThe JURYrdquoThe JURYrdquo Have your partner Have your partner

reviewreview

DocumentationDocumentation

ldquoldquoIf you didnrsquot write it on your patient If you didnrsquot write it on your patient care report you didnrsquot do itrdquocare report you didnrsquot do itrdquo

ObjectivesObjectives Importance of DocumentationImportance of Documentation Identify Data on the PCRIdentify Data on the PCR Types of Documentation FormatsTypes of Documentation Formats Consequences for Poor DocumentationConsequences for Poor Documentation Special ConsiderationsSpecial Considerations Grammar and PunctuationsGrammar and Punctuations Electronic Reporting and WARDSElectronic Reporting and WARDS

Why so ImportantWhy so Important

Permanent part of Permanent part of the patients the patients medical recordmedical record

Written Proof that Written Proof that you did somethingyou did something

Written TestimonyWritten Testimony Quality Assurance Quality Assurance Operations Operations ResearchResearch

ldquoThe content and completeness of the pre-hospital care report directly affects the lawyerrsquos impression of the incident and influences his decision of whether or not to file a lawsuitrdquo

Richard A Lazar JD

Elements of the PCRElements of the PCR Date of the RunDate of the Run Type of callType of call TIMESTIMES

ReceivedReceived EnrouteEnroute SceneScene Patient ContactPatient Contact TransportTransport DestinationDestination

Medical HistoryMedical History AllergiesAllergies MedicationsMedications Chief ComplaintChief Complaint Trauma Trauma

MechanismMechanism Safety Safety

EquipmentEquipment

Vital signsVital signs Blood Blood

PressurePressure PulsePulse RespirationsRespirations Lung SoundsLung Sounds Cap refillCap refill Blood Blood

GlucoseGlucose PupilsPupils

OrganizationOrganization

S O A PS O A P CHARTCHART CHRONOLOGICAL CHRONOLOGICAL

SOAPSOAP

What happenedWhat happened What did you What did you

findfind What do you What do you

thinkthink What did you doWhat did you do

(S) (Subjective) What happened(S) (Subjective) What happened

Medic 27 responded emergent on a 39 year old female who had a syncope from the standing position Patient reports that she

was at a party when she began to feel nauseous Walked into back room and then

passed out on floor Witnesses report patient slumped forward on to a couch and then slid

backward to a carpeted floor Patient also reports that she recalls waking up on floor feeling cold and shivering Patient moved to bed with assistance A bystander called 911

for assistance

(O) (Objective) What did you find(O) (Objective) What did you find

Upon initial contact patient laying in bed in Upon initial contact patient laying in bed in bedroom Alert and oriented to name place bedroom Alert and oriented to name place

time and event Skin warm and dry with time and event Skin warm and dry with normal color and tone Mild muscle tremors normal color and tone Mild muscle tremors

(shivers) in arms and legs Patient does (shivers) in arms and legs Patient does report feeling cold Head normocephalic report feeling cold Head normocephalic without abnormality on visualization or without abnormality on visualization or

palpation Neck midline and intact without palpation Neck midline and intact without pain on palpation or movement Thoracic pain on palpation or movement Thoracic

lumbar and sacral spine intact without pain lumbar and sacral spine intact without pain on palpation or spontaneous movementon palpation or spontaneous movement

My WayMy Way

Level of ConsciousnessLevel of Consciousness Airway Breathing CirculationAirway Breathing Circulation Skin color and tempSkin color and temp Head to Toe ExamHead to Toe Exam Pertinent NegativePertinent Negative

(A) Assessment (What do you think)(A) Assessment (What do you think)

Patient transported to Hospital with seizure Patient transported to Hospital with seizure like activitylike activity

Not a diagnosisNot a diagnosis

Protocol FollowedProtocol Followed

(P) Plan What did you do(P) Plan What did you do

Patient transported non-emergent to Aurora Patient transported non-emergent to Aurora Medical Center emergency room Patient Medical Center emergency room Patient transported without change in status or transported without change in status or

level of consciousness Patients treatment level of consciousness Patients treatment plan included full secondary assessment plan included full secondary assessment detailed neurological examination vital detailed neurological examination vital

signs cardiac monitoring pulse oximetry signs cardiac monitoring pulse oximetry and supplemental oxygen Following hand and supplemental oxygen Following hand off report to staff patient left in hospital off report to staff patient left in hospital bed with rails up and staff in attendancebed with rails up and staff in attendance

C H A R TC H A R T

Chief ComplaintChief Complaint HistoryHistory AllergiesAllergies Rx-TreatmentRx-Treatment TransportTransport

(C) Chief Complaint(C) Chief Complaint

Medic 27 responded emergent on a 39 year old female who had a syncope from the standing position

(H) History Present Illness(H) History Present Illness

HPI (history of present illnessinjury) PMH (past medical history) PQRST AMPLE MOI Onset Signs and Symptoms

(A) Assessment(A) Assessment

Include both negative and positive findings Responses the patient has to your

assessment such as the presence or lack of pain andor the presence or lack of sensation

Diagnostic Testing ECG Pulse Oximetry Capnography Blood Glucose Monitoring

(R) Rx-Treatment(R) Rx-Treatment

Document your treatmentDocument your treatment Responses from the Patient to RxResponses from the Patient to Rx Changes in Patients conditionChanges in Patients condition

Example Example ldquoPain decreased to 510 from ldquoPain decreased to 510 from 710 after NTG administered710 after NTG administered

(T) Transport(T) Transport

Where did you goWhere did you go Change in condition during Change in condition during

transporttransport Alteration from ProtocolAlteration from Protocol Who did you turn care over to Who did you turn care over to

(Name if Possible) Ie RN Robinson(Name if Possible) Ie RN Robinson Patency of airway and IV fluidsPatency of airway and IV fluids

CHRONOLOGICALCHRONOLOGICAL

ldquoldquoWrite like your brain thinks itrdquoWrite like your brain thinks itrdquo

Dispatched non-emergent to University Hospitals Dispatched non-emergent to University Hospitals Emergency Educations center for a transport to Emergency Educations center for a transport to UW ER Arrived on floor and met by staff who UW ER Arrived on floor and met by staff who advised us that the patient was suffering from advised us that the patient was suffering from severe PES (Paramedic Education Syndrome) severe PES (Paramedic Education Syndrome) Patient is Mr D a 48 yo male with hx of PES and Patient is Mr D a 48 yo male with hx of PES and CHF who presented with chest pain and CHF who presented with chest pain and dyspneahellipdyspneahellip

Errors and FalsificationsErrors and Falsifications

Avoid ErrorsAvoid Errors Admit when you made a mistakeAdmit when you made a mistake

Revise if necessaryRevise if necessary Note date and time of revisionNote date and time of revision Keep original documentKeep original document Include purpose of the revisionInclude purpose of the revision Only the original author can make the Only the original author can make the

correctioncorrection

Errors and FalsificationsErrors and Falsifications

Always be honest and through in your Always be honest and through in your documentationdocumentation

CorrectionsCorrections Add a supplement on electronic reportsAdd a supplement on electronic reports One line across the error initial the One line across the error initial the

mistake and make the corrections on mistake and make the corrections on written reportswritten reports

Complete reports as soon as possible Complete reports as soon as possible Lost reports have HUGE legal implicationsLost reports have HUGE legal implications Dont keep copies of your reportsDont keep copies of your reports

HIPPAHIPPA

What Happens on What Happens on the Ambulance the Ambulance stays on the stays on the ambulance ambulance

Health Health InsuranceInsurance PortabilityPortability PrivacyPrivacy AccountabilityAccountability

HIPPAHIPPA

Protects the security and privacy of Protects the security and privacy of all medical records and other health all medical records and other health information used or shared in any information used or shared in any formform

Protects patients rights by giving Protects patients rights by giving access to health information and access to health information and control over how it is usedcontrol over how it is used

PHIPHI Protected Heath InformationProtected Heath Information

Information that relates toInformation that relates to The health of an individualThe health of an individual Health care provided to that individualHealth care provided to that individual Payment of heath care providedPayment of heath care provided

What can be sharedWhat can be shared

Health Insurance Company my need Health Insurance Company my need information to process a claiminformation to process a claim

Caregivers involved with direct care Caregivers involved with direct care Quality Assurance when necessaryQuality Assurance when necessary

Special ConsiderationsSpecial Considerations

Exposure and InjuryExposure and Injury Mass CasualtyMass Casualty Interfacility TransportsInterfacility Transports RefusalsRefusals

Mass Casualty EventsMass Casualty Events

Documentation may have to be Documentation may have to be postponedpostponed

Follow Local Policy and ProcedureFollow Local Policy and Procedure Comprehensive run report must be Comprehensive run report must be

completed for each patient when completed for each patient when time permitstime permits

Refusal of CareRefusal of Care

Potential for LiabilityPotential for Liability Good DocumentationGood Documentation Make it clearMake it clear

Refusal of CareRefusal of Care

The litigation rate for EMS has been steadily increasing

1048657 According to one study patients evaluatedby paramedics but not transported to thehospital account for 50 to 90 of EMSlawsuitsrdquo

1048657 Documentation is your best defenserdquo

DocumentationDocumentation

Physical FindingsPhysical Findings The advice you give the patient about The advice you give the patient about

being transported and the associated being transported and the associated risks for not being transportedrisks for not being transported

Clinical indications that patient is Clinical indications that patient is competent to make a rational decisioncompetent to make a rational decision

Signatures of the patient and witnessSignatures of the patient and witness Full narrativeFull narrative Advise to call 911 if condition changesAdvise to call 911 if condition changes

Do not at any time attempt to talk the patient out of going to the hospital

If you feel strongly that the patient should be seen make every attempt to convince them they should be seen

Donrsquot say lsquo I agree you donrsquot need to gordquo even if you agree

What not to sayWhat not to say

A patient suffers a diabetic emergency She is treated by the local EMS crew with an A patient suffers a diabetic emergency She is treated by the local EMS crew with an IV an ampule of D50 and transported to the closet hospital despite family members IV an ampule of D50 and transported to the closet hospital despite family members telling you that the patient does not go theretelling you that the patient does not go there

Transport is uneventful and care is turned over to the ED Nurse with a quick verbal Transport is uneventful and care is turned over to the ED Nurse with a quick verbal reportreport

An hour later a private ambulance is called to transport the patient to her desired An hour later a private ambulance is called to transport the patient to her desired hospital for definitive care They notice the IV has infiltrated and D50 got into her hospital for definitive care They notice the IV has infiltrated and D50 got into her surrounding tissuessurrounding tissues

The patient suffers significant tissue damage which requires a fasciotomy to The patient suffers significant tissue damage which requires a fasciotomy to decompress her hand and forearm She has permanent nerve damage and requires decompress her hand and forearm She has permanent nerve damage and requires skin graftingskin grafting

Initial Transport Agency-CFDInitial Transport Agency-CFD

First Receiving Hospital-St Anthony HospitalFirst Receiving Hospital-St Anthony Hospital

Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998

Lets Finish upLets Finish up

Be ProfessionalBe Professional AccurateAccurate ConsistentConsistent ThroughThrough ClearClear BriefBrief Paint the PicturePaint the Picture CollaborativeCollaborative

Legible spelling Legible spelling correctcorrect

Tell the TruthTell the Truth Donrsquot duplicate infoDonrsquot duplicate info Follow ProtocolsFollow Protocols Plain LanguagePlain Language Relevant InformationRelevant Information ldquoldquoThe JURYrdquoThe JURYrdquo Have your partner Have your partner

reviewreview

ObjectivesObjectives Importance of DocumentationImportance of Documentation Identify Data on the PCRIdentify Data on the PCR Types of Documentation FormatsTypes of Documentation Formats Consequences for Poor DocumentationConsequences for Poor Documentation Special ConsiderationsSpecial Considerations Grammar and PunctuationsGrammar and Punctuations Electronic Reporting and WARDSElectronic Reporting and WARDS

Why so ImportantWhy so Important

Permanent part of Permanent part of the patients the patients medical recordmedical record

Written Proof that Written Proof that you did somethingyou did something

Written TestimonyWritten Testimony Quality Assurance Quality Assurance Operations Operations ResearchResearch

ldquoThe content and completeness of the pre-hospital care report directly affects the lawyerrsquos impression of the incident and influences his decision of whether or not to file a lawsuitrdquo

Richard A Lazar JD

Elements of the PCRElements of the PCR Date of the RunDate of the Run Type of callType of call TIMESTIMES

ReceivedReceived EnrouteEnroute SceneScene Patient ContactPatient Contact TransportTransport DestinationDestination

Medical HistoryMedical History AllergiesAllergies MedicationsMedications Chief ComplaintChief Complaint Trauma Trauma

MechanismMechanism Safety Safety

EquipmentEquipment

Vital signsVital signs Blood Blood

PressurePressure PulsePulse RespirationsRespirations Lung SoundsLung Sounds Cap refillCap refill Blood Blood

GlucoseGlucose PupilsPupils

OrganizationOrganization

S O A PS O A P CHARTCHART CHRONOLOGICAL CHRONOLOGICAL

SOAPSOAP

What happenedWhat happened What did you What did you

findfind What do you What do you

thinkthink What did you doWhat did you do

(S) (Subjective) What happened(S) (Subjective) What happened

Medic 27 responded emergent on a 39 year old female who had a syncope from the standing position Patient reports that she

was at a party when she began to feel nauseous Walked into back room and then

passed out on floor Witnesses report patient slumped forward on to a couch and then slid

backward to a carpeted floor Patient also reports that she recalls waking up on floor feeling cold and shivering Patient moved to bed with assistance A bystander called 911

for assistance

(O) (Objective) What did you find(O) (Objective) What did you find

Upon initial contact patient laying in bed in Upon initial contact patient laying in bed in bedroom Alert and oriented to name place bedroom Alert and oriented to name place

time and event Skin warm and dry with time and event Skin warm and dry with normal color and tone Mild muscle tremors normal color and tone Mild muscle tremors

(shivers) in arms and legs Patient does (shivers) in arms and legs Patient does report feeling cold Head normocephalic report feeling cold Head normocephalic without abnormality on visualization or without abnormality on visualization or

palpation Neck midline and intact without palpation Neck midline and intact without pain on palpation or movement Thoracic pain on palpation or movement Thoracic

lumbar and sacral spine intact without pain lumbar and sacral spine intact without pain on palpation or spontaneous movementon palpation or spontaneous movement

My WayMy Way

Level of ConsciousnessLevel of Consciousness Airway Breathing CirculationAirway Breathing Circulation Skin color and tempSkin color and temp Head to Toe ExamHead to Toe Exam Pertinent NegativePertinent Negative

(A) Assessment (What do you think)(A) Assessment (What do you think)

Patient transported to Hospital with seizure Patient transported to Hospital with seizure like activitylike activity

Not a diagnosisNot a diagnosis

Protocol FollowedProtocol Followed

(P) Plan What did you do(P) Plan What did you do

Patient transported non-emergent to Aurora Patient transported non-emergent to Aurora Medical Center emergency room Patient Medical Center emergency room Patient transported without change in status or transported without change in status or

level of consciousness Patients treatment level of consciousness Patients treatment plan included full secondary assessment plan included full secondary assessment detailed neurological examination vital detailed neurological examination vital

signs cardiac monitoring pulse oximetry signs cardiac monitoring pulse oximetry and supplemental oxygen Following hand and supplemental oxygen Following hand off report to staff patient left in hospital off report to staff patient left in hospital bed with rails up and staff in attendancebed with rails up and staff in attendance

C H A R TC H A R T

Chief ComplaintChief Complaint HistoryHistory AllergiesAllergies Rx-TreatmentRx-Treatment TransportTransport

(C) Chief Complaint(C) Chief Complaint

Medic 27 responded emergent on a 39 year old female who had a syncope from the standing position

(H) History Present Illness(H) History Present Illness

HPI (history of present illnessinjury) PMH (past medical history) PQRST AMPLE MOI Onset Signs and Symptoms

(A) Assessment(A) Assessment

Include both negative and positive findings Responses the patient has to your

assessment such as the presence or lack of pain andor the presence or lack of sensation

Diagnostic Testing ECG Pulse Oximetry Capnography Blood Glucose Monitoring

(R) Rx-Treatment(R) Rx-Treatment

Document your treatmentDocument your treatment Responses from the Patient to RxResponses from the Patient to Rx Changes in Patients conditionChanges in Patients condition

Example Example ldquoPain decreased to 510 from ldquoPain decreased to 510 from 710 after NTG administered710 after NTG administered

(T) Transport(T) Transport

Where did you goWhere did you go Change in condition during Change in condition during

transporttransport Alteration from ProtocolAlteration from Protocol Who did you turn care over to Who did you turn care over to

(Name if Possible) Ie RN Robinson(Name if Possible) Ie RN Robinson Patency of airway and IV fluidsPatency of airway and IV fluids

CHRONOLOGICALCHRONOLOGICAL

ldquoldquoWrite like your brain thinks itrdquoWrite like your brain thinks itrdquo

Dispatched non-emergent to University Hospitals Dispatched non-emergent to University Hospitals Emergency Educations center for a transport to Emergency Educations center for a transport to UW ER Arrived on floor and met by staff who UW ER Arrived on floor and met by staff who advised us that the patient was suffering from advised us that the patient was suffering from severe PES (Paramedic Education Syndrome) severe PES (Paramedic Education Syndrome) Patient is Mr D a 48 yo male with hx of PES and Patient is Mr D a 48 yo male with hx of PES and CHF who presented with chest pain and CHF who presented with chest pain and dyspneahellipdyspneahellip

Errors and FalsificationsErrors and Falsifications

Avoid ErrorsAvoid Errors Admit when you made a mistakeAdmit when you made a mistake

Revise if necessaryRevise if necessary Note date and time of revisionNote date and time of revision Keep original documentKeep original document Include purpose of the revisionInclude purpose of the revision Only the original author can make the Only the original author can make the

correctioncorrection

Errors and FalsificationsErrors and Falsifications

Always be honest and through in your Always be honest and through in your documentationdocumentation

CorrectionsCorrections Add a supplement on electronic reportsAdd a supplement on electronic reports One line across the error initial the One line across the error initial the

mistake and make the corrections on mistake and make the corrections on written reportswritten reports

Complete reports as soon as possible Complete reports as soon as possible Lost reports have HUGE legal implicationsLost reports have HUGE legal implications Dont keep copies of your reportsDont keep copies of your reports

HIPPAHIPPA

What Happens on What Happens on the Ambulance the Ambulance stays on the stays on the ambulance ambulance

Health Health InsuranceInsurance PortabilityPortability PrivacyPrivacy AccountabilityAccountability

HIPPAHIPPA

Protects the security and privacy of Protects the security and privacy of all medical records and other health all medical records and other health information used or shared in any information used or shared in any formform

Protects patients rights by giving Protects patients rights by giving access to health information and access to health information and control over how it is usedcontrol over how it is used

PHIPHI Protected Heath InformationProtected Heath Information

Information that relates toInformation that relates to The health of an individualThe health of an individual Health care provided to that individualHealth care provided to that individual Payment of heath care providedPayment of heath care provided

What can be sharedWhat can be shared

Health Insurance Company my need Health Insurance Company my need information to process a claiminformation to process a claim

Caregivers involved with direct care Caregivers involved with direct care Quality Assurance when necessaryQuality Assurance when necessary

Special ConsiderationsSpecial Considerations

Exposure and InjuryExposure and Injury Mass CasualtyMass Casualty Interfacility TransportsInterfacility Transports RefusalsRefusals

Mass Casualty EventsMass Casualty Events

Documentation may have to be Documentation may have to be postponedpostponed

Follow Local Policy and ProcedureFollow Local Policy and Procedure Comprehensive run report must be Comprehensive run report must be

completed for each patient when completed for each patient when time permitstime permits

Refusal of CareRefusal of Care

Potential for LiabilityPotential for Liability Good DocumentationGood Documentation Make it clearMake it clear

Refusal of CareRefusal of Care

The litigation rate for EMS has been steadily increasing

1048657 According to one study patients evaluatedby paramedics but not transported to thehospital account for 50 to 90 of EMSlawsuitsrdquo

1048657 Documentation is your best defenserdquo

DocumentationDocumentation

Physical FindingsPhysical Findings The advice you give the patient about The advice you give the patient about

being transported and the associated being transported and the associated risks for not being transportedrisks for not being transported

Clinical indications that patient is Clinical indications that patient is competent to make a rational decisioncompetent to make a rational decision

Signatures of the patient and witnessSignatures of the patient and witness Full narrativeFull narrative Advise to call 911 if condition changesAdvise to call 911 if condition changes

Do not at any time attempt to talk the patient out of going to the hospital

If you feel strongly that the patient should be seen make every attempt to convince them they should be seen

Donrsquot say lsquo I agree you donrsquot need to gordquo even if you agree

What not to sayWhat not to say

A patient suffers a diabetic emergency She is treated by the local EMS crew with an A patient suffers a diabetic emergency She is treated by the local EMS crew with an IV an ampule of D50 and transported to the closet hospital despite family members IV an ampule of D50 and transported to the closet hospital despite family members telling you that the patient does not go theretelling you that the patient does not go there

Transport is uneventful and care is turned over to the ED Nurse with a quick verbal Transport is uneventful and care is turned over to the ED Nurse with a quick verbal reportreport

An hour later a private ambulance is called to transport the patient to her desired An hour later a private ambulance is called to transport the patient to her desired hospital for definitive care They notice the IV has infiltrated and D50 got into her hospital for definitive care They notice the IV has infiltrated and D50 got into her surrounding tissuessurrounding tissues

The patient suffers significant tissue damage which requires a fasciotomy to The patient suffers significant tissue damage which requires a fasciotomy to decompress her hand and forearm She has permanent nerve damage and requires decompress her hand and forearm She has permanent nerve damage and requires skin graftingskin grafting

Initial Transport Agency-CFDInitial Transport Agency-CFD

First Receiving Hospital-St Anthony HospitalFirst Receiving Hospital-St Anthony Hospital

Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998

Lets Finish upLets Finish up

Be ProfessionalBe Professional AccurateAccurate ConsistentConsistent ThroughThrough ClearClear BriefBrief Paint the PicturePaint the Picture CollaborativeCollaborative

Legible spelling Legible spelling correctcorrect

Tell the TruthTell the Truth Donrsquot duplicate infoDonrsquot duplicate info Follow ProtocolsFollow Protocols Plain LanguagePlain Language Relevant InformationRelevant Information ldquoldquoThe JURYrdquoThe JURYrdquo Have your partner Have your partner

reviewreview

Why so ImportantWhy so Important

Permanent part of Permanent part of the patients the patients medical recordmedical record

Written Proof that Written Proof that you did somethingyou did something

Written TestimonyWritten Testimony Quality Assurance Quality Assurance Operations Operations ResearchResearch

ldquoThe content and completeness of the pre-hospital care report directly affects the lawyerrsquos impression of the incident and influences his decision of whether or not to file a lawsuitrdquo

Richard A Lazar JD

Elements of the PCRElements of the PCR Date of the RunDate of the Run Type of callType of call TIMESTIMES

ReceivedReceived EnrouteEnroute SceneScene Patient ContactPatient Contact TransportTransport DestinationDestination

Medical HistoryMedical History AllergiesAllergies MedicationsMedications Chief ComplaintChief Complaint Trauma Trauma

MechanismMechanism Safety Safety

EquipmentEquipment

Vital signsVital signs Blood Blood

PressurePressure PulsePulse RespirationsRespirations Lung SoundsLung Sounds Cap refillCap refill Blood Blood

GlucoseGlucose PupilsPupils

OrganizationOrganization

S O A PS O A P CHARTCHART CHRONOLOGICAL CHRONOLOGICAL

SOAPSOAP

What happenedWhat happened What did you What did you

findfind What do you What do you

thinkthink What did you doWhat did you do

(S) (Subjective) What happened(S) (Subjective) What happened

Medic 27 responded emergent on a 39 year old female who had a syncope from the standing position Patient reports that she

was at a party when she began to feel nauseous Walked into back room and then

passed out on floor Witnesses report patient slumped forward on to a couch and then slid

backward to a carpeted floor Patient also reports that she recalls waking up on floor feeling cold and shivering Patient moved to bed with assistance A bystander called 911

for assistance

(O) (Objective) What did you find(O) (Objective) What did you find

Upon initial contact patient laying in bed in Upon initial contact patient laying in bed in bedroom Alert and oriented to name place bedroom Alert and oriented to name place

time and event Skin warm and dry with time and event Skin warm and dry with normal color and tone Mild muscle tremors normal color and tone Mild muscle tremors

(shivers) in arms and legs Patient does (shivers) in arms and legs Patient does report feeling cold Head normocephalic report feeling cold Head normocephalic without abnormality on visualization or without abnormality on visualization or

palpation Neck midline and intact without palpation Neck midline and intact without pain on palpation or movement Thoracic pain on palpation or movement Thoracic

lumbar and sacral spine intact without pain lumbar and sacral spine intact without pain on palpation or spontaneous movementon palpation or spontaneous movement

My WayMy Way

Level of ConsciousnessLevel of Consciousness Airway Breathing CirculationAirway Breathing Circulation Skin color and tempSkin color and temp Head to Toe ExamHead to Toe Exam Pertinent NegativePertinent Negative

(A) Assessment (What do you think)(A) Assessment (What do you think)

Patient transported to Hospital with seizure Patient transported to Hospital with seizure like activitylike activity

Not a diagnosisNot a diagnosis

Protocol FollowedProtocol Followed

(P) Plan What did you do(P) Plan What did you do

Patient transported non-emergent to Aurora Patient transported non-emergent to Aurora Medical Center emergency room Patient Medical Center emergency room Patient transported without change in status or transported without change in status or

level of consciousness Patients treatment level of consciousness Patients treatment plan included full secondary assessment plan included full secondary assessment detailed neurological examination vital detailed neurological examination vital

signs cardiac monitoring pulse oximetry signs cardiac monitoring pulse oximetry and supplemental oxygen Following hand and supplemental oxygen Following hand off report to staff patient left in hospital off report to staff patient left in hospital bed with rails up and staff in attendancebed with rails up and staff in attendance

C H A R TC H A R T

Chief ComplaintChief Complaint HistoryHistory AllergiesAllergies Rx-TreatmentRx-Treatment TransportTransport

(C) Chief Complaint(C) Chief Complaint

Medic 27 responded emergent on a 39 year old female who had a syncope from the standing position

(H) History Present Illness(H) History Present Illness

HPI (history of present illnessinjury) PMH (past medical history) PQRST AMPLE MOI Onset Signs and Symptoms

(A) Assessment(A) Assessment

Include both negative and positive findings Responses the patient has to your

assessment such as the presence or lack of pain andor the presence or lack of sensation

Diagnostic Testing ECG Pulse Oximetry Capnography Blood Glucose Monitoring

(R) Rx-Treatment(R) Rx-Treatment

Document your treatmentDocument your treatment Responses from the Patient to RxResponses from the Patient to Rx Changes in Patients conditionChanges in Patients condition

Example Example ldquoPain decreased to 510 from ldquoPain decreased to 510 from 710 after NTG administered710 after NTG administered

(T) Transport(T) Transport

Where did you goWhere did you go Change in condition during Change in condition during

transporttransport Alteration from ProtocolAlteration from Protocol Who did you turn care over to Who did you turn care over to

(Name if Possible) Ie RN Robinson(Name if Possible) Ie RN Robinson Patency of airway and IV fluidsPatency of airway and IV fluids

CHRONOLOGICALCHRONOLOGICAL

ldquoldquoWrite like your brain thinks itrdquoWrite like your brain thinks itrdquo

Dispatched non-emergent to University Hospitals Dispatched non-emergent to University Hospitals Emergency Educations center for a transport to Emergency Educations center for a transport to UW ER Arrived on floor and met by staff who UW ER Arrived on floor and met by staff who advised us that the patient was suffering from advised us that the patient was suffering from severe PES (Paramedic Education Syndrome) severe PES (Paramedic Education Syndrome) Patient is Mr D a 48 yo male with hx of PES and Patient is Mr D a 48 yo male with hx of PES and CHF who presented with chest pain and CHF who presented with chest pain and dyspneahellipdyspneahellip

Errors and FalsificationsErrors and Falsifications

Avoid ErrorsAvoid Errors Admit when you made a mistakeAdmit when you made a mistake

Revise if necessaryRevise if necessary Note date and time of revisionNote date and time of revision Keep original documentKeep original document Include purpose of the revisionInclude purpose of the revision Only the original author can make the Only the original author can make the

correctioncorrection

Errors and FalsificationsErrors and Falsifications

Always be honest and through in your Always be honest and through in your documentationdocumentation

CorrectionsCorrections Add a supplement on electronic reportsAdd a supplement on electronic reports One line across the error initial the One line across the error initial the

mistake and make the corrections on mistake and make the corrections on written reportswritten reports

Complete reports as soon as possible Complete reports as soon as possible Lost reports have HUGE legal implicationsLost reports have HUGE legal implications Dont keep copies of your reportsDont keep copies of your reports

HIPPAHIPPA

What Happens on What Happens on the Ambulance the Ambulance stays on the stays on the ambulance ambulance

Health Health InsuranceInsurance PortabilityPortability PrivacyPrivacy AccountabilityAccountability

HIPPAHIPPA

Protects the security and privacy of Protects the security and privacy of all medical records and other health all medical records and other health information used or shared in any information used or shared in any formform

Protects patients rights by giving Protects patients rights by giving access to health information and access to health information and control over how it is usedcontrol over how it is used

PHIPHI Protected Heath InformationProtected Heath Information

Information that relates toInformation that relates to The health of an individualThe health of an individual Health care provided to that individualHealth care provided to that individual Payment of heath care providedPayment of heath care provided

What can be sharedWhat can be shared

Health Insurance Company my need Health Insurance Company my need information to process a claiminformation to process a claim

Caregivers involved with direct care Caregivers involved with direct care Quality Assurance when necessaryQuality Assurance when necessary

Special ConsiderationsSpecial Considerations

Exposure and InjuryExposure and Injury Mass CasualtyMass Casualty Interfacility TransportsInterfacility Transports RefusalsRefusals

Mass Casualty EventsMass Casualty Events

Documentation may have to be Documentation may have to be postponedpostponed

Follow Local Policy and ProcedureFollow Local Policy and Procedure Comprehensive run report must be Comprehensive run report must be

completed for each patient when completed for each patient when time permitstime permits

Refusal of CareRefusal of Care

Potential for LiabilityPotential for Liability Good DocumentationGood Documentation Make it clearMake it clear

Refusal of CareRefusal of Care

The litigation rate for EMS has been steadily increasing

1048657 According to one study patients evaluatedby paramedics but not transported to thehospital account for 50 to 90 of EMSlawsuitsrdquo

1048657 Documentation is your best defenserdquo

DocumentationDocumentation

Physical FindingsPhysical Findings The advice you give the patient about The advice you give the patient about

being transported and the associated being transported and the associated risks for not being transportedrisks for not being transported

Clinical indications that patient is Clinical indications that patient is competent to make a rational decisioncompetent to make a rational decision

Signatures of the patient and witnessSignatures of the patient and witness Full narrativeFull narrative Advise to call 911 if condition changesAdvise to call 911 if condition changes

Do not at any time attempt to talk the patient out of going to the hospital

If you feel strongly that the patient should be seen make every attempt to convince them they should be seen

Donrsquot say lsquo I agree you donrsquot need to gordquo even if you agree

What not to sayWhat not to say

A patient suffers a diabetic emergency She is treated by the local EMS crew with an A patient suffers a diabetic emergency She is treated by the local EMS crew with an IV an ampule of D50 and transported to the closet hospital despite family members IV an ampule of D50 and transported to the closet hospital despite family members telling you that the patient does not go theretelling you that the patient does not go there

Transport is uneventful and care is turned over to the ED Nurse with a quick verbal Transport is uneventful and care is turned over to the ED Nurse with a quick verbal reportreport

An hour later a private ambulance is called to transport the patient to her desired An hour later a private ambulance is called to transport the patient to her desired hospital for definitive care They notice the IV has infiltrated and D50 got into her hospital for definitive care They notice the IV has infiltrated and D50 got into her surrounding tissuessurrounding tissues

The patient suffers significant tissue damage which requires a fasciotomy to The patient suffers significant tissue damage which requires a fasciotomy to decompress her hand and forearm She has permanent nerve damage and requires decompress her hand and forearm She has permanent nerve damage and requires skin graftingskin grafting

Initial Transport Agency-CFDInitial Transport Agency-CFD

First Receiving Hospital-St Anthony HospitalFirst Receiving Hospital-St Anthony Hospital

Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998

Lets Finish upLets Finish up

Be ProfessionalBe Professional AccurateAccurate ConsistentConsistent ThroughThrough ClearClear BriefBrief Paint the PicturePaint the Picture CollaborativeCollaborative

Legible spelling Legible spelling correctcorrect

Tell the TruthTell the Truth Donrsquot duplicate infoDonrsquot duplicate info Follow ProtocolsFollow Protocols Plain LanguagePlain Language Relevant InformationRelevant Information ldquoldquoThe JURYrdquoThe JURYrdquo Have your partner Have your partner

reviewreview

ldquoThe content and completeness of the pre-hospital care report directly affects the lawyerrsquos impression of the incident and influences his decision of whether or not to file a lawsuitrdquo

Richard A Lazar JD

Elements of the PCRElements of the PCR Date of the RunDate of the Run Type of callType of call TIMESTIMES

ReceivedReceived EnrouteEnroute SceneScene Patient ContactPatient Contact TransportTransport DestinationDestination

Medical HistoryMedical History AllergiesAllergies MedicationsMedications Chief ComplaintChief Complaint Trauma Trauma

MechanismMechanism Safety Safety

EquipmentEquipment

Vital signsVital signs Blood Blood

PressurePressure PulsePulse RespirationsRespirations Lung SoundsLung Sounds Cap refillCap refill Blood Blood

GlucoseGlucose PupilsPupils

OrganizationOrganization

S O A PS O A P CHARTCHART CHRONOLOGICAL CHRONOLOGICAL

SOAPSOAP

What happenedWhat happened What did you What did you

findfind What do you What do you

thinkthink What did you doWhat did you do

(S) (Subjective) What happened(S) (Subjective) What happened

Medic 27 responded emergent on a 39 year old female who had a syncope from the standing position Patient reports that she

was at a party when she began to feel nauseous Walked into back room and then

passed out on floor Witnesses report patient slumped forward on to a couch and then slid

backward to a carpeted floor Patient also reports that she recalls waking up on floor feeling cold and shivering Patient moved to bed with assistance A bystander called 911

for assistance

(O) (Objective) What did you find(O) (Objective) What did you find

Upon initial contact patient laying in bed in Upon initial contact patient laying in bed in bedroom Alert and oriented to name place bedroom Alert and oriented to name place

time and event Skin warm and dry with time and event Skin warm and dry with normal color and tone Mild muscle tremors normal color and tone Mild muscle tremors

(shivers) in arms and legs Patient does (shivers) in arms and legs Patient does report feeling cold Head normocephalic report feeling cold Head normocephalic without abnormality on visualization or without abnormality on visualization or

palpation Neck midline and intact without palpation Neck midline and intact without pain on palpation or movement Thoracic pain on palpation or movement Thoracic

lumbar and sacral spine intact without pain lumbar and sacral spine intact without pain on palpation or spontaneous movementon palpation or spontaneous movement

My WayMy Way

Level of ConsciousnessLevel of Consciousness Airway Breathing CirculationAirway Breathing Circulation Skin color and tempSkin color and temp Head to Toe ExamHead to Toe Exam Pertinent NegativePertinent Negative

(A) Assessment (What do you think)(A) Assessment (What do you think)

Patient transported to Hospital with seizure Patient transported to Hospital with seizure like activitylike activity

Not a diagnosisNot a diagnosis

Protocol FollowedProtocol Followed

(P) Plan What did you do(P) Plan What did you do

Patient transported non-emergent to Aurora Patient transported non-emergent to Aurora Medical Center emergency room Patient Medical Center emergency room Patient transported without change in status or transported without change in status or

level of consciousness Patients treatment level of consciousness Patients treatment plan included full secondary assessment plan included full secondary assessment detailed neurological examination vital detailed neurological examination vital

signs cardiac monitoring pulse oximetry signs cardiac monitoring pulse oximetry and supplemental oxygen Following hand and supplemental oxygen Following hand off report to staff patient left in hospital off report to staff patient left in hospital bed with rails up and staff in attendancebed with rails up and staff in attendance

C H A R TC H A R T

Chief ComplaintChief Complaint HistoryHistory AllergiesAllergies Rx-TreatmentRx-Treatment TransportTransport

(C) Chief Complaint(C) Chief Complaint

Medic 27 responded emergent on a 39 year old female who had a syncope from the standing position

(H) History Present Illness(H) History Present Illness

HPI (history of present illnessinjury) PMH (past medical history) PQRST AMPLE MOI Onset Signs and Symptoms

(A) Assessment(A) Assessment

Include both negative and positive findings Responses the patient has to your

assessment such as the presence or lack of pain andor the presence or lack of sensation

Diagnostic Testing ECG Pulse Oximetry Capnography Blood Glucose Monitoring

(R) Rx-Treatment(R) Rx-Treatment

Document your treatmentDocument your treatment Responses from the Patient to RxResponses from the Patient to Rx Changes in Patients conditionChanges in Patients condition

Example Example ldquoPain decreased to 510 from ldquoPain decreased to 510 from 710 after NTG administered710 after NTG administered

(T) Transport(T) Transport

Where did you goWhere did you go Change in condition during Change in condition during

transporttransport Alteration from ProtocolAlteration from Protocol Who did you turn care over to Who did you turn care over to

(Name if Possible) Ie RN Robinson(Name if Possible) Ie RN Robinson Patency of airway and IV fluidsPatency of airway and IV fluids

CHRONOLOGICALCHRONOLOGICAL

ldquoldquoWrite like your brain thinks itrdquoWrite like your brain thinks itrdquo

Dispatched non-emergent to University Hospitals Dispatched non-emergent to University Hospitals Emergency Educations center for a transport to Emergency Educations center for a transport to UW ER Arrived on floor and met by staff who UW ER Arrived on floor and met by staff who advised us that the patient was suffering from advised us that the patient was suffering from severe PES (Paramedic Education Syndrome) severe PES (Paramedic Education Syndrome) Patient is Mr D a 48 yo male with hx of PES and Patient is Mr D a 48 yo male with hx of PES and CHF who presented with chest pain and CHF who presented with chest pain and dyspneahellipdyspneahellip

Errors and FalsificationsErrors and Falsifications

Avoid ErrorsAvoid Errors Admit when you made a mistakeAdmit when you made a mistake

Revise if necessaryRevise if necessary Note date and time of revisionNote date and time of revision Keep original documentKeep original document Include purpose of the revisionInclude purpose of the revision Only the original author can make the Only the original author can make the

correctioncorrection

Errors and FalsificationsErrors and Falsifications

Always be honest and through in your Always be honest and through in your documentationdocumentation

CorrectionsCorrections Add a supplement on electronic reportsAdd a supplement on electronic reports One line across the error initial the One line across the error initial the

mistake and make the corrections on mistake and make the corrections on written reportswritten reports

Complete reports as soon as possible Complete reports as soon as possible Lost reports have HUGE legal implicationsLost reports have HUGE legal implications Dont keep copies of your reportsDont keep copies of your reports

HIPPAHIPPA

What Happens on What Happens on the Ambulance the Ambulance stays on the stays on the ambulance ambulance

Health Health InsuranceInsurance PortabilityPortability PrivacyPrivacy AccountabilityAccountability

HIPPAHIPPA

Protects the security and privacy of Protects the security and privacy of all medical records and other health all medical records and other health information used or shared in any information used or shared in any formform

Protects patients rights by giving Protects patients rights by giving access to health information and access to health information and control over how it is usedcontrol over how it is used

PHIPHI Protected Heath InformationProtected Heath Information

Information that relates toInformation that relates to The health of an individualThe health of an individual Health care provided to that individualHealth care provided to that individual Payment of heath care providedPayment of heath care provided

What can be sharedWhat can be shared

Health Insurance Company my need Health Insurance Company my need information to process a claiminformation to process a claim

Caregivers involved with direct care Caregivers involved with direct care Quality Assurance when necessaryQuality Assurance when necessary

Special ConsiderationsSpecial Considerations

Exposure and InjuryExposure and Injury Mass CasualtyMass Casualty Interfacility TransportsInterfacility Transports RefusalsRefusals

Mass Casualty EventsMass Casualty Events

Documentation may have to be Documentation may have to be postponedpostponed

Follow Local Policy and ProcedureFollow Local Policy and Procedure Comprehensive run report must be Comprehensive run report must be

completed for each patient when completed for each patient when time permitstime permits

Refusal of CareRefusal of Care

Potential for LiabilityPotential for Liability Good DocumentationGood Documentation Make it clearMake it clear

Refusal of CareRefusal of Care

The litigation rate for EMS has been steadily increasing

1048657 According to one study patients evaluatedby paramedics but not transported to thehospital account for 50 to 90 of EMSlawsuitsrdquo

1048657 Documentation is your best defenserdquo

DocumentationDocumentation

Physical FindingsPhysical Findings The advice you give the patient about The advice you give the patient about

being transported and the associated being transported and the associated risks for not being transportedrisks for not being transported

Clinical indications that patient is Clinical indications that patient is competent to make a rational decisioncompetent to make a rational decision

Signatures of the patient and witnessSignatures of the patient and witness Full narrativeFull narrative Advise to call 911 if condition changesAdvise to call 911 if condition changes

Do not at any time attempt to talk the patient out of going to the hospital

If you feel strongly that the patient should be seen make every attempt to convince them they should be seen

Donrsquot say lsquo I agree you donrsquot need to gordquo even if you agree

What not to sayWhat not to say

A patient suffers a diabetic emergency She is treated by the local EMS crew with an A patient suffers a diabetic emergency She is treated by the local EMS crew with an IV an ampule of D50 and transported to the closet hospital despite family members IV an ampule of D50 and transported to the closet hospital despite family members telling you that the patient does not go theretelling you that the patient does not go there

Transport is uneventful and care is turned over to the ED Nurse with a quick verbal Transport is uneventful and care is turned over to the ED Nurse with a quick verbal reportreport

An hour later a private ambulance is called to transport the patient to her desired An hour later a private ambulance is called to transport the patient to her desired hospital for definitive care They notice the IV has infiltrated and D50 got into her hospital for definitive care They notice the IV has infiltrated and D50 got into her surrounding tissuessurrounding tissues

The patient suffers significant tissue damage which requires a fasciotomy to The patient suffers significant tissue damage which requires a fasciotomy to decompress her hand and forearm She has permanent nerve damage and requires decompress her hand and forearm She has permanent nerve damage and requires skin graftingskin grafting

Initial Transport Agency-CFDInitial Transport Agency-CFD

First Receiving Hospital-St Anthony HospitalFirst Receiving Hospital-St Anthony Hospital

Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998

Lets Finish upLets Finish up

Be ProfessionalBe Professional AccurateAccurate ConsistentConsistent ThroughThrough ClearClear BriefBrief Paint the PicturePaint the Picture CollaborativeCollaborative

Legible spelling Legible spelling correctcorrect

Tell the TruthTell the Truth Donrsquot duplicate infoDonrsquot duplicate info Follow ProtocolsFollow Protocols Plain LanguagePlain Language Relevant InformationRelevant Information ldquoldquoThe JURYrdquoThe JURYrdquo Have your partner Have your partner

reviewreview

Elements of the PCRElements of the PCR Date of the RunDate of the Run Type of callType of call TIMESTIMES

ReceivedReceived EnrouteEnroute SceneScene Patient ContactPatient Contact TransportTransport DestinationDestination

Medical HistoryMedical History AllergiesAllergies MedicationsMedications Chief ComplaintChief Complaint Trauma Trauma

MechanismMechanism Safety Safety

EquipmentEquipment

Vital signsVital signs Blood Blood

PressurePressure PulsePulse RespirationsRespirations Lung SoundsLung Sounds Cap refillCap refill Blood Blood

GlucoseGlucose PupilsPupils

OrganizationOrganization

S O A PS O A P CHARTCHART CHRONOLOGICAL CHRONOLOGICAL

SOAPSOAP

What happenedWhat happened What did you What did you

findfind What do you What do you

thinkthink What did you doWhat did you do

(S) (Subjective) What happened(S) (Subjective) What happened

Medic 27 responded emergent on a 39 year old female who had a syncope from the standing position Patient reports that she

was at a party when she began to feel nauseous Walked into back room and then

passed out on floor Witnesses report patient slumped forward on to a couch and then slid

backward to a carpeted floor Patient also reports that she recalls waking up on floor feeling cold and shivering Patient moved to bed with assistance A bystander called 911

for assistance

(O) (Objective) What did you find(O) (Objective) What did you find

Upon initial contact patient laying in bed in Upon initial contact patient laying in bed in bedroom Alert and oriented to name place bedroom Alert and oriented to name place

time and event Skin warm and dry with time and event Skin warm and dry with normal color and tone Mild muscle tremors normal color and tone Mild muscle tremors

(shivers) in arms and legs Patient does (shivers) in arms and legs Patient does report feeling cold Head normocephalic report feeling cold Head normocephalic without abnormality on visualization or without abnormality on visualization or

palpation Neck midline and intact without palpation Neck midline and intact without pain on palpation or movement Thoracic pain on palpation or movement Thoracic

lumbar and sacral spine intact without pain lumbar and sacral spine intact without pain on palpation or spontaneous movementon palpation or spontaneous movement

My WayMy Way

Level of ConsciousnessLevel of Consciousness Airway Breathing CirculationAirway Breathing Circulation Skin color and tempSkin color and temp Head to Toe ExamHead to Toe Exam Pertinent NegativePertinent Negative

(A) Assessment (What do you think)(A) Assessment (What do you think)

Patient transported to Hospital with seizure Patient transported to Hospital with seizure like activitylike activity

Not a diagnosisNot a diagnosis

Protocol FollowedProtocol Followed

(P) Plan What did you do(P) Plan What did you do

Patient transported non-emergent to Aurora Patient transported non-emergent to Aurora Medical Center emergency room Patient Medical Center emergency room Patient transported without change in status or transported without change in status or

level of consciousness Patients treatment level of consciousness Patients treatment plan included full secondary assessment plan included full secondary assessment detailed neurological examination vital detailed neurological examination vital

signs cardiac monitoring pulse oximetry signs cardiac monitoring pulse oximetry and supplemental oxygen Following hand and supplemental oxygen Following hand off report to staff patient left in hospital off report to staff patient left in hospital bed with rails up and staff in attendancebed with rails up and staff in attendance

C H A R TC H A R T

Chief ComplaintChief Complaint HistoryHistory AllergiesAllergies Rx-TreatmentRx-Treatment TransportTransport

(C) Chief Complaint(C) Chief Complaint

Medic 27 responded emergent on a 39 year old female who had a syncope from the standing position

(H) History Present Illness(H) History Present Illness

HPI (history of present illnessinjury) PMH (past medical history) PQRST AMPLE MOI Onset Signs and Symptoms

(A) Assessment(A) Assessment

Include both negative and positive findings Responses the patient has to your

assessment such as the presence or lack of pain andor the presence or lack of sensation

Diagnostic Testing ECG Pulse Oximetry Capnography Blood Glucose Monitoring

(R) Rx-Treatment(R) Rx-Treatment

Document your treatmentDocument your treatment Responses from the Patient to RxResponses from the Patient to Rx Changes in Patients conditionChanges in Patients condition

Example Example ldquoPain decreased to 510 from ldquoPain decreased to 510 from 710 after NTG administered710 after NTG administered

(T) Transport(T) Transport

Where did you goWhere did you go Change in condition during Change in condition during

transporttransport Alteration from ProtocolAlteration from Protocol Who did you turn care over to Who did you turn care over to

(Name if Possible) Ie RN Robinson(Name if Possible) Ie RN Robinson Patency of airway and IV fluidsPatency of airway and IV fluids

CHRONOLOGICALCHRONOLOGICAL

ldquoldquoWrite like your brain thinks itrdquoWrite like your brain thinks itrdquo

Dispatched non-emergent to University Hospitals Dispatched non-emergent to University Hospitals Emergency Educations center for a transport to Emergency Educations center for a transport to UW ER Arrived on floor and met by staff who UW ER Arrived on floor and met by staff who advised us that the patient was suffering from advised us that the patient was suffering from severe PES (Paramedic Education Syndrome) severe PES (Paramedic Education Syndrome) Patient is Mr D a 48 yo male with hx of PES and Patient is Mr D a 48 yo male with hx of PES and CHF who presented with chest pain and CHF who presented with chest pain and dyspneahellipdyspneahellip

Errors and FalsificationsErrors and Falsifications

Avoid ErrorsAvoid Errors Admit when you made a mistakeAdmit when you made a mistake

Revise if necessaryRevise if necessary Note date and time of revisionNote date and time of revision Keep original documentKeep original document Include purpose of the revisionInclude purpose of the revision Only the original author can make the Only the original author can make the

correctioncorrection

Errors and FalsificationsErrors and Falsifications

Always be honest and through in your Always be honest and through in your documentationdocumentation

CorrectionsCorrections Add a supplement on electronic reportsAdd a supplement on electronic reports One line across the error initial the One line across the error initial the

mistake and make the corrections on mistake and make the corrections on written reportswritten reports

Complete reports as soon as possible Complete reports as soon as possible Lost reports have HUGE legal implicationsLost reports have HUGE legal implications Dont keep copies of your reportsDont keep copies of your reports

HIPPAHIPPA

What Happens on What Happens on the Ambulance the Ambulance stays on the stays on the ambulance ambulance

Health Health InsuranceInsurance PortabilityPortability PrivacyPrivacy AccountabilityAccountability

HIPPAHIPPA

Protects the security and privacy of Protects the security and privacy of all medical records and other health all medical records and other health information used or shared in any information used or shared in any formform

Protects patients rights by giving Protects patients rights by giving access to health information and access to health information and control over how it is usedcontrol over how it is used

PHIPHI Protected Heath InformationProtected Heath Information

Information that relates toInformation that relates to The health of an individualThe health of an individual Health care provided to that individualHealth care provided to that individual Payment of heath care providedPayment of heath care provided

What can be sharedWhat can be shared

Health Insurance Company my need Health Insurance Company my need information to process a claiminformation to process a claim

Caregivers involved with direct care Caregivers involved with direct care Quality Assurance when necessaryQuality Assurance when necessary

Special ConsiderationsSpecial Considerations

Exposure and InjuryExposure and Injury Mass CasualtyMass Casualty Interfacility TransportsInterfacility Transports RefusalsRefusals

Mass Casualty EventsMass Casualty Events

Documentation may have to be Documentation may have to be postponedpostponed

Follow Local Policy and ProcedureFollow Local Policy and Procedure Comprehensive run report must be Comprehensive run report must be

completed for each patient when completed for each patient when time permitstime permits

Refusal of CareRefusal of Care

Potential for LiabilityPotential for Liability Good DocumentationGood Documentation Make it clearMake it clear

Refusal of CareRefusal of Care

The litigation rate for EMS has been steadily increasing

1048657 According to one study patients evaluatedby paramedics but not transported to thehospital account for 50 to 90 of EMSlawsuitsrdquo

1048657 Documentation is your best defenserdquo

DocumentationDocumentation

Physical FindingsPhysical Findings The advice you give the patient about The advice you give the patient about

being transported and the associated being transported and the associated risks for not being transportedrisks for not being transported

Clinical indications that patient is Clinical indications that patient is competent to make a rational decisioncompetent to make a rational decision

Signatures of the patient and witnessSignatures of the patient and witness Full narrativeFull narrative Advise to call 911 if condition changesAdvise to call 911 if condition changes

Do not at any time attempt to talk the patient out of going to the hospital

If you feel strongly that the patient should be seen make every attempt to convince them they should be seen

Donrsquot say lsquo I agree you donrsquot need to gordquo even if you agree

What not to sayWhat not to say

A patient suffers a diabetic emergency She is treated by the local EMS crew with an A patient suffers a diabetic emergency She is treated by the local EMS crew with an IV an ampule of D50 and transported to the closet hospital despite family members IV an ampule of D50 and transported to the closet hospital despite family members telling you that the patient does not go theretelling you that the patient does not go there

Transport is uneventful and care is turned over to the ED Nurse with a quick verbal Transport is uneventful and care is turned over to the ED Nurse with a quick verbal reportreport

An hour later a private ambulance is called to transport the patient to her desired An hour later a private ambulance is called to transport the patient to her desired hospital for definitive care They notice the IV has infiltrated and D50 got into her hospital for definitive care They notice the IV has infiltrated and D50 got into her surrounding tissuessurrounding tissues

The patient suffers significant tissue damage which requires a fasciotomy to The patient suffers significant tissue damage which requires a fasciotomy to decompress her hand and forearm She has permanent nerve damage and requires decompress her hand and forearm She has permanent nerve damage and requires skin graftingskin grafting

Initial Transport Agency-CFDInitial Transport Agency-CFD

First Receiving Hospital-St Anthony HospitalFirst Receiving Hospital-St Anthony Hospital

Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998

Lets Finish upLets Finish up

Be ProfessionalBe Professional AccurateAccurate ConsistentConsistent ThroughThrough ClearClear BriefBrief Paint the PicturePaint the Picture CollaborativeCollaborative

Legible spelling Legible spelling correctcorrect

Tell the TruthTell the Truth Donrsquot duplicate infoDonrsquot duplicate info Follow ProtocolsFollow Protocols Plain LanguagePlain Language Relevant InformationRelevant Information ldquoldquoThe JURYrdquoThe JURYrdquo Have your partner Have your partner

reviewreview

Medical HistoryMedical History AllergiesAllergies MedicationsMedications Chief ComplaintChief Complaint Trauma Trauma

MechanismMechanism Safety Safety

EquipmentEquipment

Vital signsVital signs Blood Blood

PressurePressure PulsePulse RespirationsRespirations Lung SoundsLung Sounds Cap refillCap refill Blood Blood

GlucoseGlucose PupilsPupils

OrganizationOrganization

S O A PS O A P CHARTCHART CHRONOLOGICAL CHRONOLOGICAL

SOAPSOAP

What happenedWhat happened What did you What did you

findfind What do you What do you

thinkthink What did you doWhat did you do

(S) (Subjective) What happened(S) (Subjective) What happened

Medic 27 responded emergent on a 39 year old female who had a syncope from the standing position Patient reports that she

was at a party when she began to feel nauseous Walked into back room and then

passed out on floor Witnesses report patient slumped forward on to a couch and then slid

backward to a carpeted floor Patient also reports that she recalls waking up on floor feeling cold and shivering Patient moved to bed with assistance A bystander called 911

for assistance

(O) (Objective) What did you find(O) (Objective) What did you find

Upon initial contact patient laying in bed in Upon initial contact patient laying in bed in bedroom Alert and oriented to name place bedroom Alert and oriented to name place

time and event Skin warm and dry with time and event Skin warm and dry with normal color and tone Mild muscle tremors normal color and tone Mild muscle tremors

(shivers) in arms and legs Patient does (shivers) in arms and legs Patient does report feeling cold Head normocephalic report feeling cold Head normocephalic without abnormality on visualization or without abnormality on visualization or

palpation Neck midline and intact without palpation Neck midline and intact without pain on palpation or movement Thoracic pain on palpation or movement Thoracic

lumbar and sacral spine intact without pain lumbar and sacral spine intact without pain on palpation or spontaneous movementon palpation or spontaneous movement

My WayMy Way

Level of ConsciousnessLevel of Consciousness Airway Breathing CirculationAirway Breathing Circulation Skin color and tempSkin color and temp Head to Toe ExamHead to Toe Exam Pertinent NegativePertinent Negative

(A) Assessment (What do you think)(A) Assessment (What do you think)

Patient transported to Hospital with seizure Patient transported to Hospital with seizure like activitylike activity

Not a diagnosisNot a diagnosis

Protocol FollowedProtocol Followed

(P) Plan What did you do(P) Plan What did you do

Patient transported non-emergent to Aurora Patient transported non-emergent to Aurora Medical Center emergency room Patient Medical Center emergency room Patient transported without change in status or transported without change in status or

level of consciousness Patients treatment level of consciousness Patients treatment plan included full secondary assessment plan included full secondary assessment detailed neurological examination vital detailed neurological examination vital

signs cardiac monitoring pulse oximetry signs cardiac monitoring pulse oximetry and supplemental oxygen Following hand and supplemental oxygen Following hand off report to staff patient left in hospital off report to staff patient left in hospital bed with rails up and staff in attendancebed with rails up and staff in attendance

C H A R TC H A R T

Chief ComplaintChief Complaint HistoryHistory AllergiesAllergies Rx-TreatmentRx-Treatment TransportTransport

(C) Chief Complaint(C) Chief Complaint

Medic 27 responded emergent on a 39 year old female who had a syncope from the standing position

(H) History Present Illness(H) History Present Illness

HPI (history of present illnessinjury) PMH (past medical history) PQRST AMPLE MOI Onset Signs and Symptoms

(A) Assessment(A) Assessment

Include both negative and positive findings Responses the patient has to your

assessment such as the presence or lack of pain andor the presence or lack of sensation

Diagnostic Testing ECG Pulse Oximetry Capnography Blood Glucose Monitoring

(R) Rx-Treatment(R) Rx-Treatment

Document your treatmentDocument your treatment Responses from the Patient to RxResponses from the Patient to Rx Changes in Patients conditionChanges in Patients condition

Example Example ldquoPain decreased to 510 from ldquoPain decreased to 510 from 710 after NTG administered710 after NTG administered

(T) Transport(T) Transport

Where did you goWhere did you go Change in condition during Change in condition during

transporttransport Alteration from ProtocolAlteration from Protocol Who did you turn care over to Who did you turn care over to

(Name if Possible) Ie RN Robinson(Name if Possible) Ie RN Robinson Patency of airway and IV fluidsPatency of airway and IV fluids

CHRONOLOGICALCHRONOLOGICAL

ldquoldquoWrite like your brain thinks itrdquoWrite like your brain thinks itrdquo

Dispatched non-emergent to University Hospitals Dispatched non-emergent to University Hospitals Emergency Educations center for a transport to Emergency Educations center for a transport to UW ER Arrived on floor and met by staff who UW ER Arrived on floor and met by staff who advised us that the patient was suffering from advised us that the patient was suffering from severe PES (Paramedic Education Syndrome) severe PES (Paramedic Education Syndrome) Patient is Mr D a 48 yo male with hx of PES and Patient is Mr D a 48 yo male with hx of PES and CHF who presented with chest pain and CHF who presented with chest pain and dyspneahellipdyspneahellip

Errors and FalsificationsErrors and Falsifications

Avoid ErrorsAvoid Errors Admit when you made a mistakeAdmit when you made a mistake

Revise if necessaryRevise if necessary Note date and time of revisionNote date and time of revision Keep original documentKeep original document Include purpose of the revisionInclude purpose of the revision Only the original author can make the Only the original author can make the

correctioncorrection

Errors and FalsificationsErrors and Falsifications

Always be honest and through in your Always be honest and through in your documentationdocumentation

CorrectionsCorrections Add a supplement on electronic reportsAdd a supplement on electronic reports One line across the error initial the One line across the error initial the

mistake and make the corrections on mistake and make the corrections on written reportswritten reports

Complete reports as soon as possible Complete reports as soon as possible Lost reports have HUGE legal implicationsLost reports have HUGE legal implications Dont keep copies of your reportsDont keep copies of your reports

HIPPAHIPPA

What Happens on What Happens on the Ambulance the Ambulance stays on the stays on the ambulance ambulance

Health Health InsuranceInsurance PortabilityPortability PrivacyPrivacy AccountabilityAccountability

HIPPAHIPPA

Protects the security and privacy of Protects the security and privacy of all medical records and other health all medical records and other health information used or shared in any information used or shared in any formform

Protects patients rights by giving Protects patients rights by giving access to health information and access to health information and control over how it is usedcontrol over how it is used

PHIPHI Protected Heath InformationProtected Heath Information

Information that relates toInformation that relates to The health of an individualThe health of an individual Health care provided to that individualHealth care provided to that individual Payment of heath care providedPayment of heath care provided

What can be sharedWhat can be shared

Health Insurance Company my need Health Insurance Company my need information to process a claiminformation to process a claim

Caregivers involved with direct care Caregivers involved with direct care Quality Assurance when necessaryQuality Assurance when necessary

Special ConsiderationsSpecial Considerations

Exposure and InjuryExposure and Injury Mass CasualtyMass Casualty Interfacility TransportsInterfacility Transports RefusalsRefusals

Mass Casualty EventsMass Casualty Events

Documentation may have to be Documentation may have to be postponedpostponed

Follow Local Policy and ProcedureFollow Local Policy and Procedure Comprehensive run report must be Comprehensive run report must be

completed for each patient when completed for each patient when time permitstime permits

Refusal of CareRefusal of Care

Potential for LiabilityPotential for Liability Good DocumentationGood Documentation Make it clearMake it clear

Refusal of CareRefusal of Care

The litigation rate for EMS has been steadily increasing

1048657 According to one study patients evaluatedby paramedics but not transported to thehospital account for 50 to 90 of EMSlawsuitsrdquo

1048657 Documentation is your best defenserdquo

DocumentationDocumentation

Physical FindingsPhysical Findings The advice you give the patient about The advice you give the patient about

being transported and the associated being transported and the associated risks for not being transportedrisks for not being transported

Clinical indications that patient is Clinical indications that patient is competent to make a rational decisioncompetent to make a rational decision

Signatures of the patient and witnessSignatures of the patient and witness Full narrativeFull narrative Advise to call 911 if condition changesAdvise to call 911 if condition changes

Do not at any time attempt to talk the patient out of going to the hospital

If you feel strongly that the patient should be seen make every attempt to convince them they should be seen

Donrsquot say lsquo I agree you donrsquot need to gordquo even if you agree

What not to sayWhat not to say

A patient suffers a diabetic emergency She is treated by the local EMS crew with an A patient suffers a diabetic emergency She is treated by the local EMS crew with an IV an ampule of D50 and transported to the closet hospital despite family members IV an ampule of D50 and transported to the closet hospital despite family members telling you that the patient does not go theretelling you that the patient does not go there

Transport is uneventful and care is turned over to the ED Nurse with a quick verbal Transport is uneventful and care is turned over to the ED Nurse with a quick verbal reportreport

An hour later a private ambulance is called to transport the patient to her desired An hour later a private ambulance is called to transport the patient to her desired hospital for definitive care They notice the IV has infiltrated and D50 got into her hospital for definitive care They notice the IV has infiltrated and D50 got into her surrounding tissuessurrounding tissues

The patient suffers significant tissue damage which requires a fasciotomy to The patient suffers significant tissue damage which requires a fasciotomy to decompress her hand and forearm She has permanent nerve damage and requires decompress her hand and forearm She has permanent nerve damage and requires skin graftingskin grafting

Initial Transport Agency-CFDInitial Transport Agency-CFD

First Receiving Hospital-St Anthony HospitalFirst Receiving Hospital-St Anthony Hospital

Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998

Lets Finish upLets Finish up

Be ProfessionalBe Professional AccurateAccurate ConsistentConsistent ThroughThrough ClearClear BriefBrief Paint the PicturePaint the Picture CollaborativeCollaborative

Legible spelling Legible spelling correctcorrect

Tell the TruthTell the Truth Donrsquot duplicate infoDonrsquot duplicate info Follow ProtocolsFollow Protocols Plain LanguagePlain Language Relevant InformationRelevant Information ldquoldquoThe JURYrdquoThe JURYrdquo Have your partner Have your partner

reviewreview

Vital signsVital signs Blood Blood

PressurePressure PulsePulse RespirationsRespirations Lung SoundsLung Sounds Cap refillCap refill Blood Blood

GlucoseGlucose PupilsPupils

OrganizationOrganization

S O A PS O A P CHARTCHART CHRONOLOGICAL CHRONOLOGICAL

SOAPSOAP

What happenedWhat happened What did you What did you

findfind What do you What do you

thinkthink What did you doWhat did you do

(S) (Subjective) What happened(S) (Subjective) What happened

Medic 27 responded emergent on a 39 year old female who had a syncope from the standing position Patient reports that she

was at a party when she began to feel nauseous Walked into back room and then

passed out on floor Witnesses report patient slumped forward on to a couch and then slid

backward to a carpeted floor Patient also reports that she recalls waking up on floor feeling cold and shivering Patient moved to bed with assistance A bystander called 911

for assistance

(O) (Objective) What did you find(O) (Objective) What did you find

Upon initial contact patient laying in bed in Upon initial contact patient laying in bed in bedroom Alert and oriented to name place bedroom Alert and oriented to name place

time and event Skin warm and dry with time and event Skin warm and dry with normal color and tone Mild muscle tremors normal color and tone Mild muscle tremors

(shivers) in arms and legs Patient does (shivers) in arms and legs Patient does report feeling cold Head normocephalic report feeling cold Head normocephalic without abnormality on visualization or without abnormality on visualization or

palpation Neck midline and intact without palpation Neck midline and intact without pain on palpation or movement Thoracic pain on palpation or movement Thoracic

lumbar and sacral spine intact without pain lumbar and sacral spine intact without pain on palpation or spontaneous movementon palpation or spontaneous movement

My WayMy Way

Level of ConsciousnessLevel of Consciousness Airway Breathing CirculationAirway Breathing Circulation Skin color and tempSkin color and temp Head to Toe ExamHead to Toe Exam Pertinent NegativePertinent Negative

(A) Assessment (What do you think)(A) Assessment (What do you think)

Patient transported to Hospital with seizure Patient transported to Hospital with seizure like activitylike activity

Not a diagnosisNot a diagnosis

Protocol FollowedProtocol Followed

(P) Plan What did you do(P) Plan What did you do

Patient transported non-emergent to Aurora Patient transported non-emergent to Aurora Medical Center emergency room Patient Medical Center emergency room Patient transported without change in status or transported without change in status or

level of consciousness Patients treatment level of consciousness Patients treatment plan included full secondary assessment plan included full secondary assessment detailed neurological examination vital detailed neurological examination vital

signs cardiac monitoring pulse oximetry signs cardiac monitoring pulse oximetry and supplemental oxygen Following hand and supplemental oxygen Following hand off report to staff patient left in hospital off report to staff patient left in hospital bed with rails up and staff in attendancebed with rails up and staff in attendance

C H A R TC H A R T

Chief ComplaintChief Complaint HistoryHistory AllergiesAllergies Rx-TreatmentRx-Treatment TransportTransport

(C) Chief Complaint(C) Chief Complaint

Medic 27 responded emergent on a 39 year old female who had a syncope from the standing position

(H) History Present Illness(H) History Present Illness

HPI (history of present illnessinjury) PMH (past medical history) PQRST AMPLE MOI Onset Signs and Symptoms

(A) Assessment(A) Assessment

Include both negative and positive findings Responses the patient has to your

assessment such as the presence or lack of pain andor the presence or lack of sensation

Diagnostic Testing ECG Pulse Oximetry Capnography Blood Glucose Monitoring

(R) Rx-Treatment(R) Rx-Treatment

Document your treatmentDocument your treatment Responses from the Patient to RxResponses from the Patient to Rx Changes in Patients conditionChanges in Patients condition

Example Example ldquoPain decreased to 510 from ldquoPain decreased to 510 from 710 after NTG administered710 after NTG administered

(T) Transport(T) Transport

Where did you goWhere did you go Change in condition during Change in condition during

transporttransport Alteration from ProtocolAlteration from Protocol Who did you turn care over to Who did you turn care over to

(Name if Possible) Ie RN Robinson(Name if Possible) Ie RN Robinson Patency of airway and IV fluidsPatency of airway and IV fluids

CHRONOLOGICALCHRONOLOGICAL

ldquoldquoWrite like your brain thinks itrdquoWrite like your brain thinks itrdquo

Dispatched non-emergent to University Hospitals Dispatched non-emergent to University Hospitals Emergency Educations center for a transport to Emergency Educations center for a transport to UW ER Arrived on floor and met by staff who UW ER Arrived on floor and met by staff who advised us that the patient was suffering from advised us that the patient was suffering from severe PES (Paramedic Education Syndrome) severe PES (Paramedic Education Syndrome) Patient is Mr D a 48 yo male with hx of PES and Patient is Mr D a 48 yo male with hx of PES and CHF who presented with chest pain and CHF who presented with chest pain and dyspneahellipdyspneahellip

Errors and FalsificationsErrors and Falsifications

Avoid ErrorsAvoid Errors Admit when you made a mistakeAdmit when you made a mistake

Revise if necessaryRevise if necessary Note date and time of revisionNote date and time of revision Keep original documentKeep original document Include purpose of the revisionInclude purpose of the revision Only the original author can make the Only the original author can make the

correctioncorrection

Errors and FalsificationsErrors and Falsifications

Always be honest and through in your Always be honest and through in your documentationdocumentation

CorrectionsCorrections Add a supplement on electronic reportsAdd a supplement on electronic reports One line across the error initial the One line across the error initial the

mistake and make the corrections on mistake and make the corrections on written reportswritten reports

Complete reports as soon as possible Complete reports as soon as possible Lost reports have HUGE legal implicationsLost reports have HUGE legal implications Dont keep copies of your reportsDont keep copies of your reports

HIPPAHIPPA

What Happens on What Happens on the Ambulance the Ambulance stays on the stays on the ambulance ambulance

Health Health InsuranceInsurance PortabilityPortability PrivacyPrivacy AccountabilityAccountability

HIPPAHIPPA

Protects the security and privacy of Protects the security and privacy of all medical records and other health all medical records and other health information used or shared in any information used or shared in any formform

Protects patients rights by giving Protects patients rights by giving access to health information and access to health information and control over how it is usedcontrol over how it is used

PHIPHI Protected Heath InformationProtected Heath Information

Information that relates toInformation that relates to The health of an individualThe health of an individual Health care provided to that individualHealth care provided to that individual Payment of heath care providedPayment of heath care provided

What can be sharedWhat can be shared

Health Insurance Company my need Health Insurance Company my need information to process a claiminformation to process a claim

Caregivers involved with direct care Caregivers involved with direct care Quality Assurance when necessaryQuality Assurance when necessary

Special ConsiderationsSpecial Considerations

Exposure and InjuryExposure and Injury Mass CasualtyMass Casualty Interfacility TransportsInterfacility Transports RefusalsRefusals

Mass Casualty EventsMass Casualty Events

Documentation may have to be Documentation may have to be postponedpostponed

Follow Local Policy and ProcedureFollow Local Policy and Procedure Comprehensive run report must be Comprehensive run report must be

completed for each patient when completed for each patient when time permitstime permits

Refusal of CareRefusal of Care

Potential for LiabilityPotential for Liability Good DocumentationGood Documentation Make it clearMake it clear

Refusal of CareRefusal of Care

The litigation rate for EMS has been steadily increasing

1048657 According to one study patients evaluatedby paramedics but not transported to thehospital account for 50 to 90 of EMSlawsuitsrdquo

1048657 Documentation is your best defenserdquo

DocumentationDocumentation

Physical FindingsPhysical Findings The advice you give the patient about The advice you give the patient about

being transported and the associated being transported and the associated risks for not being transportedrisks for not being transported

Clinical indications that patient is Clinical indications that patient is competent to make a rational decisioncompetent to make a rational decision

Signatures of the patient and witnessSignatures of the patient and witness Full narrativeFull narrative Advise to call 911 if condition changesAdvise to call 911 if condition changes

Do not at any time attempt to talk the patient out of going to the hospital

If you feel strongly that the patient should be seen make every attempt to convince them they should be seen

Donrsquot say lsquo I agree you donrsquot need to gordquo even if you agree

What not to sayWhat not to say

A patient suffers a diabetic emergency She is treated by the local EMS crew with an A patient suffers a diabetic emergency She is treated by the local EMS crew with an IV an ampule of D50 and transported to the closet hospital despite family members IV an ampule of D50 and transported to the closet hospital despite family members telling you that the patient does not go theretelling you that the patient does not go there

Transport is uneventful and care is turned over to the ED Nurse with a quick verbal Transport is uneventful and care is turned over to the ED Nurse with a quick verbal reportreport

An hour later a private ambulance is called to transport the patient to her desired An hour later a private ambulance is called to transport the patient to her desired hospital for definitive care They notice the IV has infiltrated and D50 got into her hospital for definitive care They notice the IV has infiltrated and D50 got into her surrounding tissuessurrounding tissues

The patient suffers significant tissue damage which requires a fasciotomy to The patient suffers significant tissue damage which requires a fasciotomy to decompress her hand and forearm She has permanent nerve damage and requires decompress her hand and forearm She has permanent nerve damage and requires skin graftingskin grafting

Initial Transport Agency-CFDInitial Transport Agency-CFD

First Receiving Hospital-St Anthony HospitalFirst Receiving Hospital-St Anthony Hospital

Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998

Lets Finish upLets Finish up

Be ProfessionalBe Professional AccurateAccurate ConsistentConsistent ThroughThrough ClearClear BriefBrief Paint the PicturePaint the Picture CollaborativeCollaborative

Legible spelling Legible spelling correctcorrect

Tell the TruthTell the Truth Donrsquot duplicate infoDonrsquot duplicate info Follow ProtocolsFollow Protocols Plain LanguagePlain Language Relevant InformationRelevant Information ldquoldquoThe JURYrdquoThe JURYrdquo Have your partner Have your partner

reviewreview

OrganizationOrganization

S O A PS O A P CHARTCHART CHRONOLOGICAL CHRONOLOGICAL

SOAPSOAP

What happenedWhat happened What did you What did you

findfind What do you What do you

thinkthink What did you doWhat did you do

(S) (Subjective) What happened(S) (Subjective) What happened

Medic 27 responded emergent on a 39 year old female who had a syncope from the standing position Patient reports that she

was at a party when she began to feel nauseous Walked into back room and then

passed out on floor Witnesses report patient slumped forward on to a couch and then slid

backward to a carpeted floor Patient also reports that she recalls waking up on floor feeling cold and shivering Patient moved to bed with assistance A bystander called 911

for assistance

(O) (Objective) What did you find(O) (Objective) What did you find

Upon initial contact patient laying in bed in Upon initial contact patient laying in bed in bedroom Alert and oriented to name place bedroom Alert and oriented to name place

time and event Skin warm and dry with time and event Skin warm and dry with normal color and tone Mild muscle tremors normal color and tone Mild muscle tremors

(shivers) in arms and legs Patient does (shivers) in arms and legs Patient does report feeling cold Head normocephalic report feeling cold Head normocephalic without abnormality on visualization or without abnormality on visualization or

palpation Neck midline and intact without palpation Neck midline and intact without pain on palpation or movement Thoracic pain on palpation or movement Thoracic

lumbar and sacral spine intact without pain lumbar and sacral spine intact without pain on palpation or spontaneous movementon palpation or spontaneous movement

My WayMy Way

Level of ConsciousnessLevel of Consciousness Airway Breathing CirculationAirway Breathing Circulation Skin color and tempSkin color and temp Head to Toe ExamHead to Toe Exam Pertinent NegativePertinent Negative

(A) Assessment (What do you think)(A) Assessment (What do you think)

Patient transported to Hospital with seizure Patient transported to Hospital with seizure like activitylike activity

Not a diagnosisNot a diagnosis

Protocol FollowedProtocol Followed

(P) Plan What did you do(P) Plan What did you do

Patient transported non-emergent to Aurora Patient transported non-emergent to Aurora Medical Center emergency room Patient Medical Center emergency room Patient transported without change in status or transported without change in status or

level of consciousness Patients treatment level of consciousness Patients treatment plan included full secondary assessment plan included full secondary assessment detailed neurological examination vital detailed neurological examination vital

signs cardiac monitoring pulse oximetry signs cardiac monitoring pulse oximetry and supplemental oxygen Following hand and supplemental oxygen Following hand off report to staff patient left in hospital off report to staff patient left in hospital bed with rails up and staff in attendancebed with rails up and staff in attendance

C H A R TC H A R T

Chief ComplaintChief Complaint HistoryHistory AllergiesAllergies Rx-TreatmentRx-Treatment TransportTransport

(C) Chief Complaint(C) Chief Complaint

Medic 27 responded emergent on a 39 year old female who had a syncope from the standing position

(H) History Present Illness(H) History Present Illness

HPI (history of present illnessinjury) PMH (past medical history) PQRST AMPLE MOI Onset Signs and Symptoms

(A) Assessment(A) Assessment

Include both negative and positive findings Responses the patient has to your

assessment such as the presence or lack of pain andor the presence or lack of sensation

Diagnostic Testing ECG Pulse Oximetry Capnography Blood Glucose Monitoring

(R) Rx-Treatment(R) Rx-Treatment

Document your treatmentDocument your treatment Responses from the Patient to RxResponses from the Patient to Rx Changes in Patients conditionChanges in Patients condition

Example Example ldquoPain decreased to 510 from ldquoPain decreased to 510 from 710 after NTG administered710 after NTG administered

(T) Transport(T) Transport

Where did you goWhere did you go Change in condition during Change in condition during

transporttransport Alteration from ProtocolAlteration from Protocol Who did you turn care over to Who did you turn care over to

(Name if Possible) Ie RN Robinson(Name if Possible) Ie RN Robinson Patency of airway and IV fluidsPatency of airway and IV fluids

CHRONOLOGICALCHRONOLOGICAL

ldquoldquoWrite like your brain thinks itrdquoWrite like your brain thinks itrdquo

Dispatched non-emergent to University Hospitals Dispatched non-emergent to University Hospitals Emergency Educations center for a transport to Emergency Educations center for a transport to UW ER Arrived on floor and met by staff who UW ER Arrived on floor and met by staff who advised us that the patient was suffering from advised us that the patient was suffering from severe PES (Paramedic Education Syndrome) severe PES (Paramedic Education Syndrome) Patient is Mr D a 48 yo male with hx of PES and Patient is Mr D a 48 yo male with hx of PES and CHF who presented with chest pain and CHF who presented with chest pain and dyspneahellipdyspneahellip

Errors and FalsificationsErrors and Falsifications

Avoid ErrorsAvoid Errors Admit when you made a mistakeAdmit when you made a mistake

Revise if necessaryRevise if necessary Note date and time of revisionNote date and time of revision Keep original documentKeep original document Include purpose of the revisionInclude purpose of the revision Only the original author can make the Only the original author can make the

correctioncorrection

Errors and FalsificationsErrors and Falsifications

Always be honest and through in your Always be honest and through in your documentationdocumentation

CorrectionsCorrections Add a supplement on electronic reportsAdd a supplement on electronic reports One line across the error initial the One line across the error initial the

mistake and make the corrections on mistake and make the corrections on written reportswritten reports

Complete reports as soon as possible Complete reports as soon as possible Lost reports have HUGE legal implicationsLost reports have HUGE legal implications Dont keep copies of your reportsDont keep copies of your reports

HIPPAHIPPA

What Happens on What Happens on the Ambulance the Ambulance stays on the stays on the ambulance ambulance

Health Health InsuranceInsurance PortabilityPortability PrivacyPrivacy AccountabilityAccountability

HIPPAHIPPA

Protects the security and privacy of Protects the security and privacy of all medical records and other health all medical records and other health information used or shared in any information used or shared in any formform

Protects patients rights by giving Protects patients rights by giving access to health information and access to health information and control over how it is usedcontrol over how it is used

PHIPHI Protected Heath InformationProtected Heath Information

Information that relates toInformation that relates to The health of an individualThe health of an individual Health care provided to that individualHealth care provided to that individual Payment of heath care providedPayment of heath care provided

What can be sharedWhat can be shared

Health Insurance Company my need Health Insurance Company my need information to process a claiminformation to process a claim

Caregivers involved with direct care Caregivers involved with direct care Quality Assurance when necessaryQuality Assurance when necessary

Special ConsiderationsSpecial Considerations

Exposure and InjuryExposure and Injury Mass CasualtyMass Casualty Interfacility TransportsInterfacility Transports RefusalsRefusals

Mass Casualty EventsMass Casualty Events

Documentation may have to be Documentation may have to be postponedpostponed

Follow Local Policy and ProcedureFollow Local Policy and Procedure Comprehensive run report must be Comprehensive run report must be

completed for each patient when completed for each patient when time permitstime permits

Refusal of CareRefusal of Care

Potential for LiabilityPotential for Liability Good DocumentationGood Documentation Make it clearMake it clear

Refusal of CareRefusal of Care

The litigation rate for EMS has been steadily increasing

1048657 According to one study patients evaluatedby paramedics but not transported to thehospital account for 50 to 90 of EMSlawsuitsrdquo

1048657 Documentation is your best defenserdquo

DocumentationDocumentation

Physical FindingsPhysical Findings The advice you give the patient about The advice you give the patient about

being transported and the associated being transported and the associated risks for not being transportedrisks for not being transported

Clinical indications that patient is Clinical indications that patient is competent to make a rational decisioncompetent to make a rational decision

Signatures of the patient and witnessSignatures of the patient and witness Full narrativeFull narrative Advise to call 911 if condition changesAdvise to call 911 if condition changes

Do not at any time attempt to talk the patient out of going to the hospital

If you feel strongly that the patient should be seen make every attempt to convince them they should be seen

Donrsquot say lsquo I agree you donrsquot need to gordquo even if you agree

What not to sayWhat not to say

A patient suffers a diabetic emergency She is treated by the local EMS crew with an A patient suffers a diabetic emergency She is treated by the local EMS crew with an IV an ampule of D50 and transported to the closet hospital despite family members IV an ampule of D50 and transported to the closet hospital despite family members telling you that the patient does not go theretelling you that the patient does not go there

Transport is uneventful and care is turned over to the ED Nurse with a quick verbal Transport is uneventful and care is turned over to the ED Nurse with a quick verbal reportreport

An hour later a private ambulance is called to transport the patient to her desired An hour later a private ambulance is called to transport the patient to her desired hospital for definitive care They notice the IV has infiltrated and D50 got into her hospital for definitive care They notice the IV has infiltrated and D50 got into her surrounding tissuessurrounding tissues

The patient suffers significant tissue damage which requires a fasciotomy to The patient suffers significant tissue damage which requires a fasciotomy to decompress her hand and forearm She has permanent nerve damage and requires decompress her hand and forearm She has permanent nerve damage and requires skin graftingskin grafting

Initial Transport Agency-CFDInitial Transport Agency-CFD

First Receiving Hospital-St Anthony HospitalFirst Receiving Hospital-St Anthony Hospital

Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998

Lets Finish upLets Finish up

Be ProfessionalBe Professional AccurateAccurate ConsistentConsistent ThroughThrough ClearClear BriefBrief Paint the PicturePaint the Picture CollaborativeCollaborative

Legible spelling Legible spelling correctcorrect

Tell the TruthTell the Truth Donrsquot duplicate infoDonrsquot duplicate info Follow ProtocolsFollow Protocols Plain LanguagePlain Language Relevant InformationRelevant Information ldquoldquoThe JURYrdquoThe JURYrdquo Have your partner Have your partner

reviewreview

SOAPSOAP

What happenedWhat happened What did you What did you

findfind What do you What do you

thinkthink What did you doWhat did you do

(S) (Subjective) What happened(S) (Subjective) What happened

Medic 27 responded emergent on a 39 year old female who had a syncope from the standing position Patient reports that she

was at a party when she began to feel nauseous Walked into back room and then

passed out on floor Witnesses report patient slumped forward on to a couch and then slid

backward to a carpeted floor Patient also reports that she recalls waking up on floor feeling cold and shivering Patient moved to bed with assistance A bystander called 911

for assistance

(O) (Objective) What did you find(O) (Objective) What did you find

Upon initial contact patient laying in bed in Upon initial contact patient laying in bed in bedroom Alert and oriented to name place bedroom Alert and oriented to name place

time and event Skin warm and dry with time and event Skin warm and dry with normal color and tone Mild muscle tremors normal color and tone Mild muscle tremors

(shivers) in arms and legs Patient does (shivers) in arms and legs Patient does report feeling cold Head normocephalic report feeling cold Head normocephalic without abnormality on visualization or without abnormality on visualization or

palpation Neck midline and intact without palpation Neck midline and intact without pain on palpation or movement Thoracic pain on palpation or movement Thoracic

lumbar and sacral spine intact without pain lumbar and sacral spine intact without pain on palpation or spontaneous movementon palpation or spontaneous movement

My WayMy Way

Level of ConsciousnessLevel of Consciousness Airway Breathing CirculationAirway Breathing Circulation Skin color and tempSkin color and temp Head to Toe ExamHead to Toe Exam Pertinent NegativePertinent Negative

(A) Assessment (What do you think)(A) Assessment (What do you think)

Patient transported to Hospital with seizure Patient transported to Hospital with seizure like activitylike activity

Not a diagnosisNot a diagnosis

Protocol FollowedProtocol Followed

(P) Plan What did you do(P) Plan What did you do

Patient transported non-emergent to Aurora Patient transported non-emergent to Aurora Medical Center emergency room Patient Medical Center emergency room Patient transported without change in status or transported without change in status or

level of consciousness Patients treatment level of consciousness Patients treatment plan included full secondary assessment plan included full secondary assessment detailed neurological examination vital detailed neurological examination vital

signs cardiac monitoring pulse oximetry signs cardiac monitoring pulse oximetry and supplemental oxygen Following hand and supplemental oxygen Following hand off report to staff patient left in hospital off report to staff patient left in hospital bed with rails up and staff in attendancebed with rails up and staff in attendance

C H A R TC H A R T

Chief ComplaintChief Complaint HistoryHistory AllergiesAllergies Rx-TreatmentRx-Treatment TransportTransport

(C) Chief Complaint(C) Chief Complaint

Medic 27 responded emergent on a 39 year old female who had a syncope from the standing position

(H) History Present Illness(H) History Present Illness

HPI (history of present illnessinjury) PMH (past medical history) PQRST AMPLE MOI Onset Signs and Symptoms

(A) Assessment(A) Assessment

Include both negative and positive findings Responses the patient has to your

assessment such as the presence or lack of pain andor the presence or lack of sensation

Diagnostic Testing ECG Pulse Oximetry Capnography Blood Glucose Monitoring

(R) Rx-Treatment(R) Rx-Treatment

Document your treatmentDocument your treatment Responses from the Patient to RxResponses from the Patient to Rx Changes in Patients conditionChanges in Patients condition

Example Example ldquoPain decreased to 510 from ldquoPain decreased to 510 from 710 after NTG administered710 after NTG administered

(T) Transport(T) Transport

Where did you goWhere did you go Change in condition during Change in condition during

transporttransport Alteration from ProtocolAlteration from Protocol Who did you turn care over to Who did you turn care over to

(Name if Possible) Ie RN Robinson(Name if Possible) Ie RN Robinson Patency of airway and IV fluidsPatency of airway and IV fluids

CHRONOLOGICALCHRONOLOGICAL

ldquoldquoWrite like your brain thinks itrdquoWrite like your brain thinks itrdquo

Dispatched non-emergent to University Hospitals Dispatched non-emergent to University Hospitals Emergency Educations center for a transport to Emergency Educations center for a transport to UW ER Arrived on floor and met by staff who UW ER Arrived on floor and met by staff who advised us that the patient was suffering from advised us that the patient was suffering from severe PES (Paramedic Education Syndrome) severe PES (Paramedic Education Syndrome) Patient is Mr D a 48 yo male with hx of PES and Patient is Mr D a 48 yo male with hx of PES and CHF who presented with chest pain and CHF who presented with chest pain and dyspneahellipdyspneahellip

Errors and FalsificationsErrors and Falsifications

Avoid ErrorsAvoid Errors Admit when you made a mistakeAdmit when you made a mistake

Revise if necessaryRevise if necessary Note date and time of revisionNote date and time of revision Keep original documentKeep original document Include purpose of the revisionInclude purpose of the revision Only the original author can make the Only the original author can make the

correctioncorrection

Errors and FalsificationsErrors and Falsifications

Always be honest and through in your Always be honest and through in your documentationdocumentation

CorrectionsCorrections Add a supplement on electronic reportsAdd a supplement on electronic reports One line across the error initial the One line across the error initial the

mistake and make the corrections on mistake and make the corrections on written reportswritten reports

Complete reports as soon as possible Complete reports as soon as possible Lost reports have HUGE legal implicationsLost reports have HUGE legal implications Dont keep copies of your reportsDont keep copies of your reports

HIPPAHIPPA

What Happens on What Happens on the Ambulance the Ambulance stays on the stays on the ambulance ambulance

Health Health InsuranceInsurance PortabilityPortability PrivacyPrivacy AccountabilityAccountability

HIPPAHIPPA

Protects the security and privacy of Protects the security and privacy of all medical records and other health all medical records and other health information used or shared in any information used or shared in any formform

Protects patients rights by giving Protects patients rights by giving access to health information and access to health information and control over how it is usedcontrol over how it is used

PHIPHI Protected Heath InformationProtected Heath Information

Information that relates toInformation that relates to The health of an individualThe health of an individual Health care provided to that individualHealth care provided to that individual Payment of heath care providedPayment of heath care provided

What can be sharedWhat can be shared

Health Insurance Company my need Health Insurance Company my need information to process a claiminformation to process a claim

Caregivers involved with direct care Caregivers involved with direct care Quality Assurance when necessaryQuality Assurance when necessary

Special ConsiderationsSpecial Considerations

Exposure and InjuryExposure and Injury Mass CasualtyMass Casualty Interfacility TransportsInterfacility Transports RefusalsRefusals

Mass Casualty EventsMass Casualty Events

Documentation may have to be Documentation may have to be postponedpostponed

Follow Local Policy and ProcedureFollow Local Policy and Procedure Comprehensive run report must be Comprehensive run report must be

completed for each patient when completed for each patient when time permitstime permits

Refusal of CareRefusal of Care

Potential for LiabilityPotential for Liability Good DocumentationGood Documentation Make it clearMake it clear

Refusal of CareRefusal of Care

The litigation rate for EMS has been steadily increasing

1048657 According to one study patients evaluatedby paramedics but not transported to thehospital account for 50 to 90 of EMSlawsuitsrdquo

1048657 Documentation is your best defenserdquo

DocumentationDocumentation

Physical FindingsPhysical Findings The advice you give the patient about The advice you give the patient about

being transported and the associated being transported and the associated risks for not being transportedrisks for not being transported

Clinical indications that patient is Clinical indications that patient is competent to make a rational decisioncompetent to make a rational decision

Signatures of the patient and witnessSignatures of the patient and witness Full narrativeFull narrative Advise to call 911 if condition changesAdvise to call 911 if condition changes

Do not at any time attempt to talk the patient out of going to the hospital

If you feel strongly that the patient should be seen make every attempt to convince them they should be seen

Donrsquot say lsquo I agree you donrsquot need to gordquo even if you agree

What not to sayWhat not to say

A patient suffers a diabetic emergency She is treated by the local EMS crew with an A patient suffers a diabetic emergency She is treated by the local EMS crew with an IV an ampule of D50 and transported to the closet hospital despite family members IV an ampule of D50 and transported to the closet hospital despite family members telling you that the patient does not go theretelling you that the patient does not go there

Transport is uneventful and care is turned over to the ED Nurse with a quick verbal Transport is uneventful and care is turned over to the ED Nurse with a quick verbal reportreport

An hour later a private ambulance is called to transport the patient to her desired An hour later a private ambulance is called to transport the patient to her desired hospital for definitive care They notice the IV has infiltrated and D50 got into her hospital for definitive care They notice the IV has infiltrated and D50 got into her surrounding tissuessurrounding tissues

The patient suffers significant tissue damage which requires a fasciotomy to The patient suffers significant tissue damage which requires a fasciotomy to decompress her hand and forearm She has permanent nerve damage and requires decompress her hand and forearm She has permanent nerve damage and requires skin graftingskin grafting

Initial Transport Agency-CFDInitial Transport Agency-CFD

First Receiving Hospital-St Anthony HospitalFirst Receiving Hospital-St Anthony Hospital

Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998

Lets Finish upLets Finish up

Be ProfessionalBe Professional AccurateAccurate ConsistentConsistent ThroughThrough ClearClear BriefBrief Paint the PicturePaint the Picture CollaborativeCollaborative

Legible spelling Legible spelling correctcorrect

Tell the TruthTell the Truth Donrsquot duplicate infoDonrsquot duplicate info Follow ProtocolsFollow Protocols Plain LanguagePlain Language Relevant InformationRelevant Information ldquoldquoThe JURYrdquoThe JURYrdquo Have your partner Have your partner

reviewreview

(S) (Subjective) What happened(S) (Subjective) What happened

Medic 27 responded emergent on a 39 year old female who had a syncope from the standing position Patient reports that she

was at a party when she began to feel nauseous Walked into back room and then

passed out on floor Witnesses report patient slumped forward on to a couch and then slid

backward to a carpeted floor Patient also reports that she recalls waking up on floor feeling cold and shivering Patient moved to bed with assistance A bystander called 911

for assistance

(O) (Objective) What did you find(O) (Objective) What did you find

Upon initial contact patient laying in bed in Upon initial contact patient laying in bed in bedroom Alert and oriented to name place bedroom Alert and oriented to name place

time and event Skin warm and dry with time and event Skin warm and dry with normal color and tone Mild muscle tremors normal color and tone Mild muscle tremors

(shivers) in arms and legs Patient does (shivers) in arms and legs Patient does report feeling cold Head normocephalic report feeling cold Head normocephalic without abnormality on visualization or without abnormality on visualization or

palpation Neck midline and intact without palpation Neck midline and intact without pain on palpation or movement Thoracic pain on palpation or movement Thoracic

lumbar and sacral spine intact without pain lumbar and sacral spine intact without pain on palpation or spontaneous movementon palpation or spontaneous movement

My WayMy Way

Level of ConsciousnessLevel of Consciousness Airway Breathing CirculationAirway Breathing Circulation Skin color and tempSkin color and temp Head to Toe ExamHead to Toe Exam Pertinent NegativePertinent Negative

(A) Assessment (What do you think)(A) Assessment (What do you think)

Patient transported to Hospital with seizure Patient transported to Hospital with seizure like activitylike activity

Not a diagnosisNot a diagnosis

Protocol FollowedProtocol Followed

(P) Plan What did you do(P) Plan What did you do

Patient transported non-emergent to Aurora Patient transported non-emergent to Aurora Medical Center emergency room Patient Medical Center emergency room Patient transported without change in status or transported without change in status or

level of consciousness Patients treatment level of consciousness Patients treatment plan included full secondary assessment plan included full secondary assessment detailed neurological examination vital detailed neurological examination vital

signs cardiac monitoring pulse oximetry signs cardiac monitoring pulse oximetry and supplemental oxygen Following hand and supplemental oxygen Following hand off report to staff patient left in hospital off report to staff patient left in hospital bed with rails up and staff in attendancebed with rails up and staff in attendance

C H A R TC H A R T

Chief ComplaintChief Complaint HistoryHistory AllergiesAllergies Rx-TreatmentRx-Treatment TransportTransport

(C) Chief Complaint(C) Chief Complaint

Medic 27 responded emergent on a 39 year old female who had a syncope from the standing position

(H) History Present Illness(H) History Present Illness

HPI (history of present illnessinjury) PMH (past medical history) PQRST AMPLE MOI Onset Signs and Symptoms

(A) Assessment(A) Assessment

Include both negative and positive findings Responses the patient has to your

assessment such as the presence or lack of pain andor the presence or lack of sensation

Diagnostic Testing ECG Pulse Oximetry Capnography Blood Glucose Monitoring

(R) Rx-Treatment(R) Rx-Treatment

Document your treatmentDocument your treatment Responses from the Patient to RxResponses from the Patient to Rx Changes in Patients conditionChanges in Patients condition

Example Example ldquoPain decreased to 510 from ldquoPain decreased to 510 from 710 after NTG administered710 after NTG administered

(T) Transport(T) Transport

Where did you goWhere did you go Change in condition during Change in condition during

transporttransport Alteration from ProtocolAlteration from Protocol Who did you turn care over to Who did you turn care over to

(Name if Possible) Ie RN Robinson(Name if Possible) Ie RN Robinson Patency of airway and IV fluidsPatency of airway and IV fluids

CHRONOLOGICALCHRONOLOGICAL

ldquoldquoWrite like your brain thinks itrdquoWrite like your brain thinks itrdquo

Dispatched non-emergent to University Hospitals Dispatched non-emergent to University Hospitals Emergency Educations center for a transport to Emergency Educations center for a transport to UW ER Arrived on floor and met by staff who UW ER Arrived on floor and met by staff who advised us that the patient was suffering from advised us that the patient was suffering from severe PES (Paramedic Education Syndrome) severe PES (Paramedic Education Syndrome) Patient is Mr D a 48 yo male with hx of PES and Patient is Mr D a 48 yo male with hx of PES and CHF who presented with chest pain and CHF who presented with chest pain and dyspneahellipdyspneahellip

Errors and FalsificationsErrors and Falsifications

Avoid ErrorsAvoid Errors Admit when you made a mistakeAdmit when you made a mistake

Revise if necessaryRevise if necessary Note date and time of revisionNote date and time of revision Keep original documentKeep original document Include purpose of the revisionInclude purpose of the revision Only the original author can make the Only the original author can make the

correctioncorrection

Errors and FalsificationsErrors and Falsifications

Always be honest and through in your Always be honest and through in your documentationdocumentation

CorrectionsCorrections Add a supplement on electronic reportsAdd a supplement on electronic reports One line across the error initial the One line across the error initial the

mistake and make the corrections on mistake and make the corrections on written reportswritten reports

Complete reports as soon as possible Complete reports as soon as possible Lost reports have HUGE legal implicationsLost reports have HUGE legal implications Dont keep copies of your reportsDont keep copies of your reports

HIPPAHIPPA

What Happens on What Happens on the Ambulance the Ambulance stays on the stays on the ambulance ambulance

Health Health InsuranceInsurance PortabilityPortability PrivacyPrivacy AccountabilityAccountability

HIPPAHIPPA

Protects the security and privacy of Protects the security and privacy of all medical records and other health all medical records and other health information used or shared in any information used or shared in any formform

Protects patients rights by giving Protects patients rights by giving access to health information and access to health information and control over how it is usedcontrol over how it is used

PHIPHI Protected Heath InformationProtected Heath Information

Information that relates toInformation that relates to The health of an individualThe health of an individual Health care provided to that individualHealth care provided to that individual Payment of heath care providedPayment of heath care provided

What can be sharedWhat can be shared

Health Insurance Company my need Health Insurance Company my need information to process a claiminformation to process a claim

Caregivers involved with direct care Caregivers involved with direct care Quality Assurance when necessaryQuality Assurance when necessary

Special ConsiderationsSpecial Considerations

Exposure and InjuryExposure and Injury Mass CasualtyMass Casualty Interfacility TransportsInterfacility Transports RefusalsRefusals

Mass Casualty EventsMass Casualty Events

Documentation may have to be Documentation may have to be postponedpostponed

Follow Local Policy and ProcedureFollow Local Policy and Procedure Comprehensive run report must be Comprehensive run report must be

completed for each patient when completed for each patient when time permitstime permits

Refusal of CareRefusal of Care

Potential for LiabilityPotential for Liability Good DocumentationGood Documentation Make it clearMake it clear

Refusal of CareRefusal of Care

The litigation rate for EMS has been steadily increasing

1048657 According to one study patients evaluatedby paramedics but not transported to thehospital account for 50 to 90 of EMSlawsuitsrdquo

1048657 Documentation is your best defenserdquo

DocumentationDocumentation

Physical FindingsPhysical Findings The advice you give the patient about The advice you give the patient about

being transported and the associated being transported and the associated risks for not being transportedrisks for not being transported

Clinical indications that patient is Clinical indications that patient is competent to make a rational decisioncompetent to make a rational decision

Signatures of the patient and witnessSignatures of the patient and witness Full narrativeFull narrative Advise to call 911 if condition changesAdvise to call 911 if condition changes

Do not at any time attempt to talk the patient out of going to the hospital

If you feel strongly that the patient should be seen make every attempt to convince them they should be seen

Donrsquot say lsquo I agree you donrsquot need to gordquo even if you agree

What not to sayWhat not to say

A patient suffers a diabetic emergency She is treated by the local EMS crew with an A patient suffers a diabetic emergency She is treated by the local EMS crew with an IV an ampule of D50 and transported to the closet hospital despite family members IV an ampule of D50 and transported to the closet hospital despite family members telling you that the patient does not go theretelling you that the patient does not go there

Transport is uneventful and care is turned over to the ED Nurse with a quick verbal Transport is uneventful and care is turned over to the ED Nurse with a quick verbal reportreport

An hour later a private ambulance is called to transport the patient to her desired An hour later a private ambulance is called to transport the patient to her desired hospital for definitive care They notice the IV has infiltrated and D50 got into her hospital for definitive care They notice the IV has infiltrated and D50 got into her surrounding tissuessurrounding tissues

The patient suffers significant tissue damage which requires a fasciotomy to The patient suffers significant tissue damage which requires a fasciotomy to decompress her hand and forearm She has permanent nerve damage and requires decompress her hand and forearm She has permanent nerve damage and requires skin graftingskin grafting

Initial Transport Agency-CFDInitial Transport Agency-CFD

First Receiving Hospital-St Anthony HospitalFirst Receiving Hospital-St Anthony Hospital

Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998

Lets Finish upLets Finish up

Be ProfessionalBe Professional AccurateAccurate ConsistentConsistent ThroughThrough ClearClear BriefBrief Paint the PicturePaint the Picture CollaborativeCollaborative

Legible spelling Legible spelling correctcorrect

Tell the TruthTell the Truth Donrsquot duplicate infoDonrsquot duplicate info Follow ProtocolsFollow Protocols Plain LanguagePlain Language Relevant InformationRelevant Information ldquoldquoThe JURYrdquoThe JURYrdquo Have your partner Have your partner

reviewreview

(O) (Objective) What did you find(O) (Objective) What did you find

Upon initial contact patient laying in bed in Upon initial contact patient laying in bed in bedroom Alert and oriented to name place bedroom Alert and oriented to name place

time and event Skin warm and dry with time and event Skin warm and dry with normal color and tone Mild muscle tremors normal color and tone Mild muscle tremors

(shivers) in arms and legs Patient does (shivers) in arms and legs Patient does report feeling cold Head normocephalic report feeling cold Head normocephalic without abnormality on visualization or without abnormality on visualization or

palpation Neck midline and intact without palpation Neck midline and intact without pain on palpation or movement Thoracic pain on palpation or movement Thoracic

lumbar and sacral spine intact without pain lumbar and sacral spine intact without pain on palpation or spontaneous movementon palpation or spontaneous movement

My WayMy Way

Level of ConsciousnessLevel of Consciousness Airway Breathing CirculationAirway Breathing Circulation Skin color and tempSkin color and temp Head to Toe ExamHead to Toe Exam Pertinent NegativePertinent Negative

(A) Assessment (What do you think)(A) Assessment (What do you think)

Patient transported to Hospital with seizure Patient transported to Hospital with seizure like activitylike activity

Not a diagnosisNot a diagnosis

Protocol FollowedProtocol Followed

(P) Plan What did you do(P) Plan What did you do

Patient transported non-emergent to Aurora Patient transported non-emergent to Aurora Medical Center emergency room Patient Medical Center emergency room Patient transported without change in status or transported without change in status or

level of consciousness Patients treatment level of consciousness Patients treatment plan included full secondary assessment plan included full secondary assessment detailed neurological examination vital detailed neurological examination vital

signs cardiac monitoring pulse oximetry signs cardiac monitoring pulse oximetry and supplemental oxygen Following hand and supplemental oxygen Following hand off report to staff patient left in hospital off report to staff patient left in hospital bed with rails up and staff in attendancebed with rails up and staff in attendance

C H A R TC H A R T

Chief ComplaintChief Complaint HistoryHistory AllergiesAllergies Rx-TreatmentRx-Treatment TransportTransport

(C) Chief Complaint(C) Chief Complaint

Medic 27 responded emergent on a 39 year old female who had a syncope from the standing position

(H) History Present Illness(H) History Present Illness

HPI (history of present illnessinjury) PMH (past medical history) PQRST AMPLE MOI Onset Signs and Symptoms

(A) Assessment(A) Assessment

Include both negative and positive findings Responses the patient has to your

assessment such as the presence or lack of pain andor the presence or lack of sensation

Diagnostic Testing ECG Pulse Oximetry Capnography Blood Glucose Monitoring

(R) Rx-Treatment(R) Rx-Treatment

Document your treatmentDocument your treatment Responses from the Patient to RxResponses from the Patient to Rx Changes in Patients conditionChanges in Patients condition

Example Example ldquoPain decreased to 510 from ldquoPain decreased to 510 from 710 after NTG administered710 after NTG administered

(T) Transport(T) Transport

Where did you goWhere did you go Change in condition during Change in condition during

transporttransport Alteration from ProtocolAlteration from Protocol Who did you turn care over to Who did you turn care over to

(Name if Possible) Ie RN Robinson(Name if Possible) Ie RN Robinson Patency of airway and IV fluidsPatency of airway and IV fluids

CHRONOLOGICALCHRONOLOGICAL

ldquoldquoWrite like your brain thinks itrdquoWrite like your brain thinks itrdquo

Dispatched non-emergent to University Hospitals Dispatched non-emergent to University Hospitals Emergency Educations center for a transport to Emergency Educations center for a transport to UW ER Arrived on floor and met by staff who UW ER Arrived on floor and met by staff who advised us that the patient was suffering from advised us that the patient was suffering from severe PES (Paramedic Education Syndrome) severe PES (Paramedic Education Syndrome) Patient is Mr D a 48 yo male with hx of PES and Patient is Mr D a 48 yo male with hx of PES and CHF who presented with chest pain and CHF who presented with chest pain and dyspneahellipdyspneahellip

Errors and FalsificationsErrors and Falsifications

Avoid ErrorsAvoid Errors Admit when you made a mistakeAdmit when you made a mistake

Revise if necessaryRevise if necessary Note date and time of revisionNote date and time of revision Keep original documentKeep original document Include purpose of the revisionInclude purpose of the revision Only the original author can make the Only the original author can make the

correctioncorrection

Errors and FalsificationsErrors and Falsifications

Always be honest and through in your Always be honest and through in your documentationdocumentation

CorrectionsCorrections Add a supplement on electronic reportsAdd a supplement on electronic reports One line across the error initial the One line across the error initial the

mistake and make the corrections on mistake and make the corrections on written reportswritten reports

Complete reports as soon as possible Complete reports as soon as possible Lost reports have HUGE legal implicationsLost reports have HUGE legal implications Dont keep copies of your reportsDont keep copies of your reports

HIPPAHIPPA

What Happens on What Happens on the Ambulance the Ambulance stays on the stays on the ambulance ambulance

Health Health InsuranceInsurance PortabilityPortability PrivacyPrivacy AccountabilityAccountability

HIPPAHIPPA

Protects the security and privacy of Protects the security and privacy of all medical records and other health all medical records and other health information used or shared in any information used or shared in any formform

Protects patients rights by giving Protects patients rights by giving access to health information and access to health information and control over how it is usedcontrol over how it is used

PHIPHI Protected Heath InformationProtected Heath Information

Information that relates toInformation that relates to The health of an individualThe health of an individual Health care provided to that individualHealth care provided to that individual Payment of heath care providedPayment of heath care provided

What can be sharedWhat can be shared

Health Insurance Company my need Health Insurance Company my need information to process a claiminformation to process a claim

Caregivers involved with direct care Caregivers involved with direct care Quality Assurance when necessaryQuality Assurance when necessary

Special ConsiderationsSpecial Considerations

Exposure and InjuryExposure and Injury Mass CasualtyMass Casualty Interfacility TransportsInterfacility Transports RefusalsRefusals

Mass Casualty EventsMass Casualty Events

Documentation may have to be Documentation may have to be postponedpostponed

Follow Local Policy and ProcedureFollow Local Policy and Procedure Comprehensive run report must be Comprehensive run report must be

completed for each patient when completed for each patient when time permitstime permits

Refusal of CareRefusal of Care

Potential for LiabilityPotential for Liability Good DocumentationGood Documentation Make it clearMake it clear

Refusal of CareRefusal of Care

The litigation rate for EMS has been steadily increasing

1048657 According to one study patients evaluatedby paramedics but not transported to thehospital account for 50 to 90 of EMSlawsuitsrdquo

1048657 Documentation is your best defenserdquo

DocumentationDocumentation

Physical FindingsPhysical Findings The advice you give the patient about The advice you give the patient about

being transported and the associated being transported and the associated risks for not being transportedrisks for not being transported

Clinical indications that patient is Clinical indications that patient is competent to make a rational decisioncompetent to make a rational decision

Signatures of the patient and witnessSignatures of the patient and witness Full narrativeFull narrative Advise to call 911 if condition changesAdvise to call 911 if condition changes

Do not at any time attempt to talk the patient out of going to the hospital

If you feel strongly that the patient should be seen make every attempt to convince them they should be seen

Donrsquot say lsquo I agree you donrsquot need to gordquo even if you agree

What not to sayWhat not to say

A patient suffers a diabetic emergency She is treated by the local EMS crew with an A patient suffers a diabetic emergency She is treated by the local EMS crew with an IV an ampule of D50 and transported to the closet hospital despite family members IV an ampule of D50 and transported to the closet hospital despite family members telling you that the patient does not go theretelling you that the patient does not go there

Transport is uneventful and care is turned over to the ED Nurse with a quick verbal Transport is uneventful and care is turned over to the ED Nurse with a quick verbal reportreport

An hour later a private ambulance is called to transport the patient to her desired An hour later a private ambulance is called to transport the patient to her desired hospital for definitive care They notice the IV has infiltrated and D50 got into her hospital for definitive care They notice the IV has infiltrated and D50 got into her surrounding tissuessurrounding tissues

The patient suffers significant tissue damage which requires a fasciotomy to The patient suffers significant tissue damage which requires a fasciotomy to decompress her hand and forearm She has permanent nerve damage and requires decompress her hand and forearm She has permanent nerve damage and requires skin graftingskin grafting

Initial Transport Agency-CFDInitial Transport Agency-CFD

First Receiving Hospital-St Anthony HospitalFirst Receiving Hospital-St Anthony Hospital

Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998

Lets Finish upLets Finish up

Be ProfessionalBe Professional AccurateAccurate ConsistentConsistent ThroughThrough ClearClear BriefBrief Paint the PicturePaint the Picture CollaborativeCollaborative

Legible spelling Legible spelling correctcorrect

Tell the TruthTell the Truth Donrsquot duplicate infoDonrsquot duplicate info Follow ProtocolsFollow Protocols Plain LanguagePlain Language Relevant InformationRelevant Information ldquoldquoThe JURYrdquoThe JURYrdquo Have your partner Have your partner

reviewreview

My WayMy Way

Level of ConsciousnessLevel of Consciousness Airway Breathing CirculationAirway Breathing Circulation Skin color and tempSkin color and temp Head to Toe ExamHead to Toe Exam Pertinent NegativePertinent Negative

(A) Assessment (What do you think)(A) Assessment (What do you think)

Patient transported to Hospital with seizure Patient transported to Hospital with seizure like activitylike activity

Not a diagnosisNot a diagnosis

Protocol FollowedProtocol Followed

(P) Plan What did you do(P) Plan What did you do

Patient transported non-emergent to Aurora Patient transported non-emergent to Aurora Medical Center emergency room Patient Medical Center emergency room Patient transported without change in status or transported without change in status or

level of consciousness Patients treatment level of consciousness Patients treatment plan included full secondary assessment plan included full secondary assessment detailed neurological examination vital detailed neurological examination vital

signs cardiac monitoring pulse oximetry signs cardiac monitoring pulse oximetry and supplemental oxygen Following hand and supplemental oxygen Following hand off report to staff patient left in hospital off report to staff patient left in hospital bed with rails up and staff in attendancebed with rails up and staff in attendance

C H A R TC H A R T

Chief ComplaintChief Complaint HistoryHistory AllergiesAllergies Rx-TreatmentRx-Treatment TransportTransport

(C) Chief Complaint(C) Chief Complaint

Medic 27 responded emergent on a 39 year old female who had a syncope from the standing position

(H) History Present Illness(H) History Present Illness

HPI (history of present illnessinjury) PMH (past medical history) PQRST AMPLE MOI Onset Signs and Symptoms

(A) Assessment(A) Assessment

Include both negative and positive findings Responses the patient has to your

assessment such as the presence or lack of pain andor the presence or lack of sensation

Diagnostic Testing ECG Pulse Oximetry Capnography Blood Glucose Monitoring

(R) Rx-Treatment(R) Rx-Treatment

Document your treatmentDocument your treatment Responses from the Patient to RxResponses from the Patient to Rx Changes in Patients conditionChanges in Patients condition

Example Example ldquoPain decreased to 510 from ldquoPain decreased to 510 from 710 after NTG administered710 after NTG administered

(T) Transport(T) Transport

Where did you goWhere did you go Change in condition during Change in condition during

transporttransport Alteration from ProtocolAlteration from Protocol Who did you turn care over to Who did you turn care over to

(Name if Possible) Ie RN Robinson(Name if Possible) Ie RN Robinson Patency of airway and IV fluidsPatency of airway and IV fluids

CHRONOLOGICALCHRONOLOGICAL

ldquoldquoWrite like your brain thinks itrdquoWrite like your brain thinks itrdquo

Dispatched non-emergent to University Hospitals Dispatched non-emergent to University Hospitals Emergency Educations center for a transport to Emergency Educations center for a transport to UW ER Arrived on floor and met by staff who UW ER Arrived on floor and met by staff who advised us that the patient was suffering from advised us that the patient was suffering from severe PES (Paramedic Education Syndrome) severe PES (Paramedic Education Syndrome) Patient is Mr D a 48 yo male with hx of PES and Patient is Mr D a 48 yo male with hx of PES and CHF who presented with chest pain and CHF who presented with chest pain and dyspneahellipdyspneahellip

Errors and FalsificationsErrors and Falsifications

Avoid ErrorsAvoid Errors Admit when you made a mistakeAdmit when you made a mistake

Revise if necessaryRevise if necessary Note date and time of revisionNote date and time of revision Keep original documentKeep original document Include purpose of the revisionInclude purpose of the revision Only the original author can make the Only the original author can make the

correctioncorrection

Errors and FalsificationsErrors and Falsifications

Always be honest and through in your Always be honest and through in your documentationdocumentation

CorrectionsCorrections Add a supplement on electronic reportsAdd a supplement on electronic reports One line across the error initial the One line across the error initial the

mistake and make the corrections on mistake and make the corrections on written reportswritten reports

Complete reports as soon as possible Complete reports as soon as possible Lost reports have HUGE legal implicationsLost reports have HUGE legal implications Dont keep copies of your reportsDont keep copies of your reports

HIPPAHIPPA

What Happens on What Happens on the Ambulance the Ambulance stays on the stays on the ambulance ambulance

Health Health InsuranceInsurance PortabilityPortability PrivacyPrivacy AccountabilityAccountability

HIPPAHIPPA

Protects the security and privacy of Protects the security and privacy of all medical records and other health all medical records and other health information used or shared in any information used or shared in any formform

Protects patients rights by giving Protects patients rights by giving access to health information and access to health information and control over how it is usedcontrol over how it is used

PHIPHI Protected Heath InformationProtected Heath Information

Information that relates toInformation that relates to The health of an individualThe health of an individual Health care provided to that individualHealth care provided to that individual Payment of heath care providedPayment of heath care provided

What can be sharedWhat can be shared

Health Insurance Company my need Health Insurance Company my need information to process a claiminformation to process a claim

Caregivers involved with direct care Caregivers involved with direct care Quality Assurance when necessaryQuality Assurance when necessary

Special ConsiderationsSpecial Considerations

Exposure and InjuryExposure and Injury Mass CasualtyMass Casualty Interfacility TransportsInterfacility Transports RefusalsRefusals

Mass Casualty EventsMass Casualty Events

Documentation may have to be Documentation may have to be postponedpostponed

Follow Local Policy and ProcedureFollow Local Policy and Procedure Comprehensive run report must be Comprehensive run report must be

completed for each patient when completed for each patient when time permitstime permits

Refusal of CareRefusal of Care

Potential for LiabilityPotential for Liability Good DocumentationGood Documentation Make it clearMake it clear

Refusal of CareRefusal of Care

The litigation rate for EMS has been steadily increasing

1048657 According to one study patients evaluatedby paramedics but not transported to thehospital account for 50 to 90 of EMSlawsuitsrdquo

1048657 Documentation is your best defenserdquo

DocumentationDocumentation

Physical FindingsPhysical Findings The advice you give the patient about The advice you give the patient about

being transported and the associated being transported and the associated risks for not being transportedrisks for not being transported

Clinical indications that patient is Clinical indications that patient is competent to make a rational decisioncompetent to make a rational decision

Signatures of the patient and witnessSignatures of the patient and witness Full narrativeFull narrative Advise to call 911 if condition changesAdvise to call 911 if condition changes

Do not at any time attempt to talk the patient out of going to the hospital

If you feel strongly that the patient should be seen make every attempt to convince them they should be seen

Donrsquot say lsquo I agree you donrsquot need to gordquo even if you agree

What not to sayWhat not to say

A patient suffers a diabetic emergency She is treated by the local EMS crew with an A patient suffers a diabetic emergency She is treated by the local EMS crew with an IV an ampule of D50 and transported to the closet hospital despite family members IV an ampule of D50 and transported to the closet hospital despite family members telling you that the patient does not go theretelling you that the patient does not go there

Transport is uneventful and care is turned over to the ED Nurse with a quick verbal Transport is uneventful and care is turned over to the ED Nurse with a quick verbal reportreport

An hour later a private ambulance is called to transport the patient to her desired An hour later a private ambulance is called to transport the patient to her desired hospital for definitive care They notice the IV has infiltrated and D50 got into her hospital for definitive care They notice the IV has infiltrated and D50 got into her surrounding tissuessurrounding tissues

The patient suffers significant tissue damage which requires a fasciotomy to The patient suffers significant tissue damage which requires a fasciotomy to decompress her hand and forearm She has permanent nerve damage and requires decompress her hand and forearm She has permanent nerve damage and requires skin graftingskin grafting

Initial Transport Agency-CFDInitial Transport Agency-CFD

First Receiving Hospital-St Anthony HospitalFirst Receiving Hospital-St Anthony Hospital

Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998

Lets Finish upLets Finish up

Be ProfessionalBe Professional AccurateAccurate ConsistentConsistent ThroughThrough ClearClear BriefBrief Paint the PicturePaint the Picture CollaborativeCollaborative

Legible spelling Legible spelling correctcorrect

Tell the TruthTell the Truth Donrsquot duplicate infoDonrsquot duplicate info Follow ProtocolsFollow Protocols Plain LanguagePlain Language Relevant InformationRelevant Information ldquoldquoThe JURYrdquoThe JURYrdquo Have your partner Have your partner

reviewreview

(A) Assessment (What do you think)(A) Assessment (What do you think)

Patient transported to Hospital with seizure Patient transported to Hospital with seizure like activitylike activity

Not a diagnosisNot a diagnosis

Protocol FollowedProtocol Followed

(P) Plan What did you do(P) Plan What did you do

Patient transported non-emergent to Aurora Patient transported non-emergent to Aurora Medical Center emergency room Patient Medical Center emergency room Patient transported without change in status or transported without change in status or

level of consciousness Patients treatment level of consciousness Patients treatment plan included full secondary assessment plan included full secondary assessment detailed neurological examination vital detailed neurological examination vital

signs cardiac monitoring pulse oximetry signs cardiac monitoring pulse oximetry and supplemental oxygen Following hand and supplemental oxygen Following hand off report to staff patient left in hospital off report to staff patient left in hospital bed with rails up and staff in attendancebed with rails up and staff in attendance

C H A R TC H A R T

Chief ComplaintChief Complaint HistoryHistory AllergiesAllergies Rx-TreatmentRx-Treatment TransportTransport

(C) Chief Complaint(C) Chief Complaint

Medic 27 responded emergent on a 39 year old female who had a syncope from the standing position

(H) History Present Illness(H) History Present Illness

HPI (history of present illnessinjury) PMH (past medical history) PQRST AMPLE MOI Onset Signs and Symptoms

(A) Assessment(A) Assessment

Include both negative and positive findings Responses the patient has to your

assessment such as the presence or lack of pain andor the presence or lack of sensation

Diagnostic Testing ECG Pulse Oximetry Capnography Blood Glucose Monitoring

(R) Rx-Treatment(R) Rx-Treatment

Document your treatmentDocument your treatment Responses from the Patient to RxResponses from the Patient to Rx Changes in Patients conditionChanges in Patients condition

Example Example ldquoPain decreased to 510 from ldquoPain decreased to 510 from 710 after NTG administered710 after NTG administered

(T) Transport(T) Transport

Where did you goWhere did you go Change in condition during Change in condition during

transporttransport Alteration from ProtocolAlteration from Protocol Who did you turn care over to Who did you turn care over to

(Name if Possible) Ie RN Robinson(Name if Possible) Ie RN Robinson Patency of airway and IV fluidsPatency of airway and IV fluids

CHRONOLOGICALCHRONOLOGICAL

ldquoldquoWrite like your brain thinks itrdquoWrite like your brain thinks itrdquo

Dispatched non-emergent to University Hospitals Dispatched non-emergent to University Hospitals Emergency Educations center for a transport to Emergency Educations center for a transport to UW ER Arrived on floor and met by staff who UW ER Arrived on floor and met by staff who advised us that the patient was suffering from advised us that the patient was suffering from severe PES (Paramedic Education Syndrome) severe PES (Paramedic Education Syndrome) Patient is Mr D a 48 yo male with hx of PES and Patient is Mr D a 48 yo male with hx of PES and CHF who presented with chest pain and CHF who presented with chest pain and dyspneahellipdyspneahellip

Errors and FalsificationsErrors and Falsifications

Avoid ErrorsAvoid Errors Admit when you made a mistakeAdmit when you made a mistake

Revise if necessaryRevise if necessary Note date and time of revisionNote date and time of revision Keep original documentKeep original document Include purpose of the revisionInclude purpose of the revision Only the original author can make the Only the original author can make the

correctioncorrection

Errors and FalsificationsErrors and Falsifications

Always be honest and through in your Always be honest and through in your documentationdocumentation

CorrectionsCorrections Add a supplement on electronic reportsAdd a supplement on electronic reports One line across the error initial the One line across the error initial the

mistake and make the corrections on mistake and make the corrections on written reportswritten reports

Complete reports as soon as possible Complete reports as soon as possible Lost reports have HUGE legal implicationsLost reports have HUGE legal implications Dont keep copies of your reportsDont keep copies of your reports

HIPPAHIPPA

What Happens on What Happens on the Ambulance the Ambulance stays on the stays on the ambulance ambulance

Health Health InsuranceInsurance PortabilityPortability PrivacyPrivacy AccountabilityAccountability

HIPPAHIPPA

Protects the security and privacy of Protects the security and privacy of all medical records and other health all medical records and other health information used or shared in any information used or shared in any formform

Protects patients rights by giving Protects patients rights by giving access to health information and access to health information and control over how it is usedcontrol over how it is used

PHIPHI Protected Heath InformationProtected Heath Information

Information that relates toInformation that relates to The health of an individualThe health of an individual Health care provided to that individualHealth care provided to that individual Payment of heath care providedPayment of heath care provided

What can be sharedWhat can be shared

Health Insurance Company my need Health Insurance Company my need information to process a claiminformation to process a claim

Caregivers involved with direct care Caregivers involved with direct care Quality Assurance when necessaryQuality Assurance when necessary

Special ConsiderationsSpecial Considerations

Exposure and InjuryExposure and Injury Mass CasualtyMass Casualty Interfacility TransportsInterfacility Transports RefusalsRefusals

Mass Casualty EventsMass Casualty Events

Documentation may have to be Documentation may have to be postponedpostponed

Follow Local Policy and ProcedureFollow Local Policy and Procedure Comprehensive run report must be Comprehensive run report must be

completed for each patient when completed for each patient when time permitstime permits

Refusal of CareRefusal of Care

Potential for LiabilityPotential for Liability Good DocumentationGood Documentation Make it clearMake it clear

Refusal of CareRefusal of Care

The litigation rate for EMS has been steadily increasing

1048657 According to one study patients evaluatedby paramedics but not transported to thehospital account for 50 to 90 of EMSlawsuitsrdquo

1048657 Documentation is your best defenserdquo

DocumentationDocumentation

Physical FindingsPhysical Findings The advice you give the patient about The advice you give the patient about

being transported and the associated being transported and the associated risks for not being transportedrisks for not being transported

Clinical indications that patient is Clinical indications that patient is competent to make a rational decisioncompetent to make a rational decision

Signatures of the patient and witnessSignatures of the patient and witness Full narrativeFull narrative Advise to call 911 if condition changesAdvise to call 911 if condition changes

Do not at any time attempt to talk the patient out of going to the hospital

If you feel strongly that the patient should be seen make every attempt to convince them they should be seen

Donrsquot say lsquo I agree you donrsquot need to gordquo even if you agree

What not to sayWhat not to say

A patient suffers a diabetic emergency She is treated by the local EMS crew with an A patient suffers a diabetic emergency She is treated by the local EMS crew with an IV an ampule of D50 and transported to the closet hospital despite family members IV an ampule of D50 and transported to the closet hospital despite family members telling you that the patient does not go theretelling you that the patient does not go there

Transport is uneventful and care is turned over to the ED Nurse with a quick verbal Transport is uneventful and care is turned over to the ED Nurse with a quick verbal reportreport

An hour later a private ambulance is called to transport the patient to her desired An hour later a private ambulance is called to transport the patient to her desired hospital for definitive care They notice the IV has infiltrated and D50 got into her hospital for definitive care They notice the IV has infiltrated and D50 got into her surrounding tissuessurrounding tissues

The patient suffers significant tissue damage which requires a fasciotomy to The patient suffers significant tissue damage which requires a fasciotomy to decompress her hand and forearm She has permanent nerve damage and requires decompress her hand and forearm She has permanent nerve damage and requires skin graftingskin grafting

Initial Transport Agency-CFDInitial Transport Agency-CFD

First Receiving Hospital-St Anthony HospitalFirst Receiving Hospital-St Anthony Hospital

Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998

Lets Finish upLets Finish up

Be ProfessionalBe Professional AccurateAccurate ConsistentConsistent ThroughThrough ClearClear BriefBrief Paint the PicturePaint the Picture CollaborativeCollaborative

Legible spelling Legible spelling correctcorrect

Tell the TruthTell the Truth Donrsquot duplicate infoDonrsquot duplicate info Follow ProtocolsFollow Protocols Plain LanguagePlain Language Relevant InformationRelevant Information ldquoldquoThe JURYrdquoThe JURYrdquo Have your partner Have your partner

reviewreview

(P) Plan What did you do(P) Plan What did you do

Patient transported non-emergent to Aurora Patient transported non-emergent to Aurora Medical Center emergency room Patient Medical Center emergency room Patient transported without change in status or transported without change in status or

level of consciousness Patients treatment level of consciousness Patients treatment plan included full secondary assessment plan included full secondary assessment detailed neurological examination vital detailed neurological examination vital

signs cardiac monitoring pulse oximetry signs cardiac monitoring pulse oximetry and supplemental oxygen Following hand and supplemental oxygen Following hand off report to staff patient left in hospital off report to staff patient left in hospital bed with rails up and staff in attendancebed with rails up and staff in attendance

C H A R TC H A R T

Chief ComplaintChief Complaint HistoryHistory AllergiesAllergies Rx-TreatmentRx-Treatment TransportTransport

(C) Chief Complaint(C) Chief Complaint

Medic 27 responded emergent on a 39 year old female who had a syncope from the standing position

(H) History Present Illness(H) History Present Illness

HPI (history of present illnessinjury) PMH (past medical history) PQRST AMPLE MOI Onset Signs and Symptoms

(A) Assessment(A) Assessment

Include both negative and positive findings Responses the patient has to your

assessment such as the presence or lack of pain andor the presence or lack of sensation

Diagnostic Testing ECG Pulse Oximetry Capnography Blood Glucose Monitoring

(R) Rx-Treatment(R) Rx-Treatment

Document your treatmentDocument your treatment Responses from the Patient to RxResponses from the Patient to Rx Changes in Patients conditionChanges in Patients condition

Example Example ldquoPain decreased to 510 from ldquoPain decreased to 510 from 710 after NTG administered710 after NTG administered

(T) Transport(T) Transport

Where did you goWhere did you go Change in condition during Change in condition during

transporttransport Alteration from ProtocolAlteration from Protocol Who did you turn care over to Who did you turn care over to

(Name if Possible) Ie RN Robinson(Name if Possible) Ie RN Robinson Patency of airway and IV fluidsPatency of airway and IV fluids

CHRONOLOGICALCHRONOLOGICAL

ldquoldquoWrite like your brain thinks itrdquoWrite like your brain thinks itrdquo

Dispatched non-emergent to University Hospitals Dispatched non-emergent to University Hospitals Emergency Educations center for a transport to Emergency Educations center for a transport to UW ER Arrived on floor and met by staff who UW ER Arrived on floor and met by staff who advised us that the patient was suffering from advised us that the patient was suffering from severe PES (Paramedic Education Syndrome) severe PES (Paramedic Education Syndrome) Patient is Mr D a 48 yo male with hx of PES and Patient is Mr D a 48 yo male with hx of PES and CHF who presented with chest pain and CHF who presented with chest pain and dyspneahellipdyspneahellip

Errors and FalsificationsErrors and Falsifications

Avoid ErrorsAvoid Errors Admit when you made a mistakeAdmit when you made a mistake

Revise if necessaryRevise if necessary Note date and time of revisionNote date and time of revision Keep original documentKeep original document Include purpose of the revisionInclude purpose of the revision Only the original author can make the Only the original author can make the

correctioncorrection

Errors and FalsificationsErrors and Falsifications

Always be honest and through in your Always be honest and through in your documentationdocumentation

CorrectionsCorrections Add a supplement on electronic reportsAdd a supplement on electronic reports One line across the error initial the One line across the error initial the

mistake and make the corrections on mistake and make the corrections on written reportswritten reports

Complete reports as soon as possible Complete reports as soon as possible Lost reports have HUGE legal implicationsLost reports have HUGE legal implications Dont keep copies of your reportsDont keep copies of your reports

HIPPAHIPPA

What Happens on What Happens on the Ambulance the Ambulance stays on the stays on the ambulance ambulance

Health Health InsuranceInsurance PortabilityPortability PrivacyPrivacy AccountabilityAccountability

HIPPAHIPPA

Protects the security and privacy of Protects the security and privacy of all medical records and other health all medical records and other health information used or shared in any information used or shared in any formform

Protects patients rights by giving Protects patients rights by giving access to health information and access to health information and control over how it is usedcontrol over how it is used

PHIPHI Protected Heath InformationProtected Heath Information

Information that relates toInformation that relates to The health of an individualThe health of an individual Health care provided to that individualHealth care provided to that individual Payment of heath care providedPayment of heath care provided

What can be sharedWhat can be shared

Health Insurance Company my need Health Insurance Company my need information to process a claiminformation to process a claim

Caregivers involved with direct care Caregivers involved with direct care Quality Assurance when necessaryQuality Assurance when necessary

Special ConsiderationsSpecial Considerations

Exposure and InjuryExposure and Injury Mass CasualtyMass Casualty Interfacility TransportsInterfacility Transports RefusalsRefusals

Mass Casualty EventsMass Casualty Events

Documentation may have to be Documentation may have to be postponedpostponed

Follow Local Policy and ProcedureFollow Local Policy and Procedure Comprehensive run report must be Comprehensive run report must be

completed for each patient when completed for each patient when time permitstime permits

Refusal of CareRefusal of Care

Potential for LiabilityPotential for Liability Good DocumentationGood Documentation Make it clearMake it clear

Refusal of CareRefusal of Care

The litigation rate for EMS has been steadily increasing

1048657 According to one study patients evaluatedby paramedics but not transported to thehospital account for 50 to 90 of EMSlawsuitsrdquo

1048657 Documentation is your best defenserdquo

DocumentationDocumentation

Physical FindingsPhysical Findings The advice you give the patient about The advice you give the patient about

being transported and the associated being transported and the associated risks for not being transportedrisks for not being transported

Clinical indications that patient is Clinical indications that patient is competent to make a rational decisioncompetent to make a rational decision

Signatures of the patient and witnessSignatures of the patient and witness Full narrativeFull narrative Advise to call 911 if condition changesAdvise to call 911 if condition changes

Do not at any time attempt to talk the patient out of going to the hospital

If you feel strongly that the patient should be seen make every attempt to convince them they should be seen

Donrsquot say lsquo I agree you donrsquot need to gordquo even if you agree

What not to sayWhat not to say

A patient suffers a diabetic emergency She is treated by the local EMS crew with an A patient suffers a diabetic emergency She is treated by the local EMS crew with an IV an ampule of D50 and transported to the closet hospital despite family members IV an ampule of D50 and transported to the closet hospital despite family members telling you that the patient does not go theretelling you that the patient does not go there

Transport is uneventful and care is turned over to the ED Nurse with a quick verbal Transport is uneventful and care is turned over to the ED Nurse with a quick verbal reportreport

An hour later a private ambulance is called to transport the patient to her desired An hour later a private ambulance is called to transport the patient to her desired hospital for definitive care They notice the IV has infiltrated and D50 got into her hospital for definitive care They notice the IV has infiltrated and D50 got into her surrounding tissuessurrounding tissues

The patient suffers significant tissue damage which requires a fasciotomy to The patient suffers significant tissue damage which requires a fasciotomy to decompress her hand and forearm She has permanent nerve damage and requires decompress her hand and forearm She has permanent nerve damage and requires skin graftingskin grafting

Initial Transport Agency-CFDInitial Transport Agency-CFD

First Receiving Hospital-St Anthony HospitalFirst Receiving Hospital-St Anthony Hospital

Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998

Lets Finish upLets Finish up

Be ProfessionalBe Professional AccurateAccurate ConsistentConsistent ThroughThrough ClearClear BriefBrief Paint the PicturePaint the Picture CollaborativeCollaborative

Legible spelling Legible spelling correctcorrect

Tell the TruthTell the Truth Donrsquot duplicate infoDonrsquot duplicate info Follow ProtocolsFollow Protocols Plain LanguagePlain Language Relevant InformationRelevant Information ldquoldquoThe JURYrdquoThe JURYrdquo Have your partner Have your partner

reviewreview

C H A R TC H A R T

Chief ComplaintChief Complaint HistoryHistory AllergiesAllergies Rx-TreatmentRx-Treatment TransportTransport

(C) Chief Complaint(C) Chief Complaint

Medic 27 responded emergent on a 39 year old female who had a syncope from the standing position

(H) History Present Illness(H) History Present Illness

HPI (history of present illnessinjury) PMH (past medical history) PQRST AMPLE MOI Onset Signs and Symptoms

(A) Assessment(A) Assessment

Include both negative and positive findings Responses the patient has to your

assessment such as the presence or lack of pain andor the presence or lack of sensation

Diagnostic Testing ECG Pulse Oximetry Capnography Blood Glucose Monitoring

(R) Rx-Treatment(R) Rx-Treatment

Document your treatmentDocument your treatment Responses from the Patient to RxResponses from the Patient to Rx Changes in Patients conditionChanges in Patients condition

Example Example ldquoPain decreased to 510 from ldquoPain decreased to 510 from 710 after NTG administered710 after NTG administered

(T) Transport(T) Transport

Where did you goWhere did you go Change in condition during Change in condition during

transporttransport Alteration from ProtocolAlteration from Protocol Who did you turn care over to Who did you turn care over to

(Name if Possible) Ie RN Robinson(Name if Possible) Ie RN Robinson Patency of airway and IV fluidsPatency of airway and IV fluids

CHRONOLOGICALCHRONOLOGICAL

ldquoldquoWrite like your brain thinks itrdquoWrite like your brain thinks itrdquo

Dispatched non-emergent to University Hospitals Dispatched non-emergent to University Hospitals Emergency Educations center for a transport to Emergency Educations center for a transport to UW ER Arrived on floor and met by staff who UW ER Arrived on floor and met by staff who advised us that the patient was suffering from advised us that the patient was suffering from severe PES (Paramedic Education Syndrome) severe PES (Paramedic Education Syndrome) Patient is Mr D a 48 yo male with hx of PES and Patient is Mr D a 48 yo male with hx of PES and CHF who presented with chest pain and CHF who presented with chest pain and dyspneahellipdyspneahellip

Errors and FalsificationsErrors and Falsifications

Avoid ErrorsAvoid Errors Admit when you made a mistakeAdmit when you made a mistake

Revise if necessaryRevise if necessary Note date and time of revisionNote date and time of revision Keep original documentKeep original document Include purpose of the revisionInclude purpose of the revision Only the original author can make the Only the original author can make the

correctioncorrection

Errors and FalsificationsErrors and Falsifications

Always be honest and through in your Always be honest and through in your documentationdocumentation

CorrectionsCorrections Add a supplement on electronic reportsAdd a supplement on electronic reports One line across the error initial the One line across the error initial the

mistake and make the corrections on mistake and make the corrections on written reportswritten reports

Complete reports as soon as possible Complete reports as soon as possible Lost reports have HUGE legal implicationsLost reports have HUGE legal implications Dont keep copies of your reportsDont keep copies of your reports

HIPPAHIPPA

What Happens on What Happens on the Ambulance the Ambulance stays on the stays on the ambulance ambulance

Health Health InsuranceInsurance PortabilityPortability PrivacyPrivacy AccountabilityAccountability

HIPPAHIPPA

Protects the security and privacy of Protects the security and privacy of all medical records and other health all medical records and other health information used or shared in any information used or shared in any formform

Protects patients rights by giving Protects patients rights by giving access to health information and access to health information and control over how it is usedcontrol over how it is used

PHIPHI Protected Heath InformationProtected Heath Information

Information that relates toInformation that relates to The health of an individualThe health of an individual Health care provided to that individualHealth care provided to that individual Payment of heath care providedPayment of heath care provided

What can be sharedWhat can be shared

Health Insurance Company my need Health Insurance Company my need information to process a claiminformation to process a claim

Caregivers involved with direct care Caregivers involved with direct care Quality Assurance when necessaryQuality Assurance when necessary

Special ConsiderationsSpecial Considerations

Exposure and InjuryExposure and Injury Mass CasualtyMass Casualty Interfacility TransportsInterfacility Transports RefusalsRefusals

Mass Casualty EventsMass Casualty Events

Documentation may have to be Documentation may have to be postponedpostponed

Follow Local Policy and ProcedureFollow Local Policy and Procedure Comprehensive run report must be Comprehensive run report must be

completed for each patient when completed for each patient when time permitstime permits

Refusal of CareRefusal of Care

Potential for LiabilityPotential for Liability Good DocumentationGood Documentation Make it clearMake it clear

Refusal of CareRefusal of Care

The litigation rate for EMS has been steadily increasing

1048657 According to one study patients evaluatedby paramedics but not transported to thehospital account for 50 to 90 of EMSlawsuitsrdquo

1048657 Documentation is your best defenserdquo

DocumentationDocumentation

Physical FindingsPhysical Findings The advice you give the patient about The advice you give the patient about

being transported and the associated being transported and the associated risks for not being transportedrisks for not being transported

Clinical indications that patient is Clinical indications that patient is competent to make a rational decisioncompetent to make a rational decision

Signatures of the patient and witnessSignatures of the patient and witness Full narrativeFull narrative Advise to call 911 if condition changesAdvise to call 911 if condition changes

Do not at any time attempt to talk the patient out of going to the hospital

If you feel strongly that the patient should be seen make every attempt to convince them they should be seen

Donrsquot say lsquo I agree you donrsquot need to gordquo even if you agree

What not to sayWhat not to say

A patient suffers a diabetic emergency She is treated by the local EMS crew with an A patient suffers a diabetic emergency She is treated by the local EMS crew with an IV an ampule of D50 and transported to the closet hospital despite family members IV an ampule of D50 and transported to the closet hospital despite family members telling you that the patient does not go theretelling you that the patient does not go there

Transport is uneventful and care is turned over to the ED Nurse with a quick verbal Transport is uneventful and care is turned over to the ED Nurse with a quick verbal reportreport

An hour later a private ambulance is called to transport the patient to her desired An hour later a private ambulance is called to transport the patient to her desired hospital for definitive care They notice the IV has infiltrated and D50 got into her hospital for definitive care They notice the IV has infiltrated and D50 got into her surrounding tissuessurrounding tissues

The patient suffers significant tissue damage which requires a fasciotomy to The patient suffers significant tissue damage which requires a fasciotomy to decompress her hand and forearm She has permanent nerve damage and requires decompress her hand and forearm She has permanent nerve damage and requires skin graftingskin grafting

Initial Transport Agency-CFDInitial Transport Agency-CFD

First Receiving Hospital-St Anthony HospitalFirst Receiving Hospital-St Anthony Hospital

Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998

Lets Finish upLets Finish up

Be ProfessionalBe Professional AccurateAccurate ConsistentConsistent ThroughThrough ClearClear BriefBrief Paint the PicturePaint the Picture CollaborativeCollaborative

Legible spelling Legible spelling correctcorrect

Tell the TruthTell the Truth Donrsquot duplicate infoDonrsquot duplicate info Follow ProtocolsFollow Protocols Plain LanguagePlain Language Relevant InformationRelevant Information ldquoldquoThe JURYrdquoThe JURYrdquo Have your partner Have your partner

reviewreview

(C) Chief Complaint(C) Chief Complaint

Medic 27 responded emergent on a 39 year old female who had a syncope from the standing position

(H) History Present Illness(H) History Present Illness

HPI (history of present illnessinjury) PMH (past medical history) PQRST AMPLE MOI Onset Signs and Symptoms

(A) Assessment(A) Assessment

Include both negative and positive findings Responses the patient has to your

assessment such as the presence or lack of pain andor the presence or lack of sensation

Diagnostic Testing ECG Pulse Oximetry Capnography Blood Glucose Monitoring

(R) Rx-Treatment(R) Rx-Treatment

Document your treatmentDocument your treatment Responses from the Patient to RxResponses from the Patient to Rx Changes in Patients conditionChanges in Patients condition

Example Example ldquoPain decreased to 510 from ldquoPain decreased to 510 from 710 after NTG administered710 after NTG administered

(T) Transport(T) Transport

Where did you goWhere did you go Change in condition during Change in condition during

transporttransport Alteration from ProtocolAlteration from Protocol Who did you turn care over to Who did you turn care over to

(Name if Possible) Ie RN Robinson(Name if Possible) Ie RN Robinson Patency of airway and IV fluidsPatency of airway and IV fluids

CHRONOLOGICALCHRONOLOGICAL

ldquoldquoWrite like your brain thinks itrdquoWrite like your brain thinks itrdquo

Dispatched non-emergent to University Hospitals Dispatched non-emergent to University Hospitals Emergency Educations center for a transport to Emergency Educations center for a transport to UW ER Arrived on floor and met by staff who UW ER Arrived on floor and met by staff who advised us that the patient was suffering from advised us that the patient was suffering from severe PES (Paramedic Education Syndrome) severe PES (Paramedic Education Syndrome) Patient is Mr D a 48 yo male with hx of PES and Patient is Mr D a 48 yo male with hx of PES and CHF who presented with chest pain and CHF who presented with chest pain and dyspneahellipdyspneahellip

Errors and FalsificationsErrors and Falsifications

Avoid ErrorsAvoid Errors Admit when you made a mistakeAdmit when you made a mistake

Revise if necessaryRevise if necessary Note date and time of revisionNote date and time of revision Keep original documentKeep original document Include purpose of the revisionInclude purpose of the revision Only the original author can make the Only the original author can make the

correctioncorrection

Errors and FalsificationsErrors and Falsifications

Always be honest and through in your Always be honest and through in your documentationdocumentation

CorrectionsCorrections Add a supplement on electronic reportsAdd a supplement on electronic reports One line across the error initial the One line across the error initial the

mistake and make the corrections on mistake and make the corrections on written reportswritten reports

Complete reports as soon as possible Complete reports as soon as possible Lost reports have HUGE legal implicationsLost reports have HUGE legal implications Dont keep copies of your reportsDont keep copies of your reports

HIPPAHIPPA

What Happens on What Happens on the Ambulance the Ambulance stays on the stays on the ambulance ambulance

Health Health InsuranceInsurance PortabilityPortability PrivacyPrivacy AccountabilityAccountability

HIPPAHIPPA

Protects the security and privacy of Protects the security and privacy of all medical records and other health all medical records and other health information used or shared in any information used or shared in any formform

Protects patients rights by giving Protects patients rights by giving access to health information and access to health information and control over how it is usedcontrol over how it is used

PHIPHI Protected Heath InformationProtected Heath Information

Information that relates toInformation that relates to The health of an individualThe health of an individual Health care provided to that individualHealth care provided to that individual Payment of heath care providedPayment of heath care provided

What can be sharedWhat can be shared

Health Insurance Company my need Health Insurance Company my need information to process a claiminformation to process a claim

Caregivers involved with direct care Caregivers involved with direct care Quality Assurance when necessaryQuality Assurance when necessary

Special ConsiderationsSpecial Considerations

Exposure and InjuryExposure and Injury Mass CasualtyMass Casualty Interfacility TransportsInterfacility Transports RefusalsRefusals

Mass Casualty EventsMass Casualty Events

Documentation may have to be Documentation may have to be postponedpostponed

Follow Local Policy and ProcedureFollow Local Policy and Procedure Comprehensive run report must be Comprehensive run report must be

completed for each patient when completed for each patient when time permitstime permits

Refusal of CareRefusal of Care

Potential for LiabilityPotential for Liability Good DocumentationGood Documentation Make it clearMake it clear

Refusal of CareRefusal of Care

The litigation rate for EMS has been steadily increasing

1048657 According to one study patients evaluatedby paramedics but not transported to thehospital account for 50 to 90 of EMSlawsuitsrdquo

1048657 Documentation is your best defenserdquo

DocumentationDocumentation

Physical FindingsPhysical Findings The advice you give the patient about The advice you give the patient about

being transported and the associated being transported and the associated risks for not being transportedrisks for not being transported

Clinical indications that patient is Clinical indications that patient is competent to make a rational decisioncompetent to make a rational decision

Signatures of the patient and witnessSignatures of the patient and witness Full narrativeFull narrative Advise to call 911 if condition changesAdvise to call 911 if condition changes

Do not at any time attempt to talk the patient out of going to the hospital

If you feel strongly that the patient should be seen make every attempt to convince them they should be seen

Donrsquot say lsquo I agree you donrsquot need to gordquo even if you agree

What not to sayWhat not to say

A patient suffers a diabetic emergency She is treated by the local EMS crew with an A patient suffers a diabetic emergency She is treated by the local EMS crew with an IV an ampule of D50 and transported to the closet hospital despite family members IV an ampule of D50 and transported to the closet hospital despite family members telling you that the patient does not go theretelling you that the patient does not go there

Transport is uneventful and care is turned over to the ED Nurse with a quick verbal Transport is uneventful and care is turned over to the ED Nurse with a quick verbal reportreport

An hour later a private ambulance is called to transport the patient to her desired An hour later a private ambulance is called to transport the patient to her desired hospital for definitive care They notice the IV has infiltrated and D50 got into her hospital for definitive care They notice the IV has infiltrated and D50 got into her surrounding tissuessurrounding tissues

The patient suffers significant tissue damage which requires a fasciotomy to The patient suffers significant tissue damage which requires a fasciotomy to decompress her hand and forearm She has permanent nerve damage and requires decompress her hand and forearm She has permanent nerve damage and requires skin graftingskin grafting

Initial Transport Agency-CFDInitial Transport Agency-CFD

First Receiving Hospital-St Anthony HospitalFirst Receiving Hospital-St Anthony Hospital

Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998

Lets Finish upLets Finish up

Be ProfessionalBe Professional AccurateAccurate ConsistentConsistent ThroughThrough ClearClear BriefBrief Paint the PicturePaint the Picture CollaborativeCollaborative

Legible spelling Legible spelling correctcorrect

Tell the TruthTell the Truth Donrsquot duplicate infoDonrsquot duplicate info Follow ProtocolsFollow Protocols Plain LanguagePlain Language Relevant InformationRelevant Information ldquoldquoThe JURYrdquoThe JURYrdquo Have your partner Have your partner

reviewreview

(H) History Present Illness(H) History Present Illness

HPI (history of present illnessinjury) PMH (past medical history) PQRST AMPLE MOI Onset Signs and Symptoms

(A) Assessment(A) Assessment

Include both negative and positive findings Responses the patient has to your

assessment such as the presence or lack of pain andor the presence or lack of sensation

Diagnostic Testing ECG Pulse Oximetry Capnography Blood Glucose Monitoring

(R) Rx-Treatment(R) Rx-Treatment

Document your treatmentDocument your treatment Responses from the Patient to RxResponses from the Patient to Rx Changes in Patients conditionChanges in Patients condition

Example Example ldquoPain decreased to 510 from ldquoPain decreased to 510 from 710 after NTG administered710 after NTG administered

(T) Transport(T) Transport

Where did you goWhere did you go Change in condition during Change in condition during

transporttransport Alteration from ProtocolAlteration from Protocol Who did you turn care over to Who did you turn care over to

(Name if Possible) Ie RN Robinson(Name if Possible) Ie RN Robinson Patency of airway and IV fluidsPatency of airway and IV fluids

CHRONOLOGICALCHRONOLOGICAL

ldquoldquoWrite like your brain thinks itrdquoWrite like your brain thinks itrdquo

Dispatched non-emergent to University Hospitals Dispatched non-emergent to University Hospitals Emergency Educations center for a transport to Emergency Educations center for a transport to UW ER Arrived on floor and met by staff who UW ER Arrived on floor and met by staff who advised us that the patient was suffering from advised us that the patient was suffering from severe PES (Paramedic Education Syndrome) severe PES (Paramedic Education Syndrome) Patient is Mr D a 48 yo male with hx of PES and Patient is Mr D a 48 yo male with hx of PES and CHF who presented with chest pain and CHF who presented with chest pain and dyspneahellipdyspneahellip

Errors and FalsificationsErrors and Falsifications

Avoid ErrorsAvoid Errors Admit when you made a mistakeAdmit when you made a mistake

Revise if necessaryRevise if necessary Note date and time of revisionNote date and time of revision Keep original documentKeep original document Include purpose of the revisionInclude purpose of the revision Only the original author can make the Only the original author can make the

correctioncorrection

Errors and FalsificationsErrors and Falsifications

Always be honest and through in your Always be honest and through in your documentationdocumentation

CorrectionsCorrections Add a supplement on electronic reportsAdd a supplement on electronic reports One line across the error initial the One line across the error initial the

mistake and make the corrections on mistake and make the corrections on written reportswritten reports

Complete reports as soon as possible Complete reports as soon as possible Lost reports have HUGE legal implicationsLost reports have HUGE legal implications Dont keep copies of your reportsDont keep copies of your reports

HIPPAHIPPA

What Happens on What Happens on the Ambulance the Ambulance stays on the stays on the ambulance ambulance

Health Health InsuranceInsurance PortabilityPortability PrivacyPrivacy AccountabilityAccountability

HIPPAHIPPA

Protects the security and privacy of Protects the security and privacy of all medical records and other health all medical records and other health information used or shared in any information used or shared in any formform

Protects patients rights by giving Protects patients rights by giving access to health information and access to health information and control over how it is usedcontrol over how it is used

PHIPHI Protected Heath InformationProtected Heath Information

Information that relates toInformation that relates to The health of an individualThe health of an individual Health care provided to that individualHealth care provided to that individual Payment of heath care providedPayment of heath care provided

What can be sharedWhat can be shared

Health Insurance Company my need Health Insurance Company my need information to process a claiminformation to process a claim

Caregivers involved with direct care Caregivers involved with direct care Quality Assurance when necessaryQuality Assurance when necessary

Special ConsiderationsSpecial Considerations

Exposure and InjuryExposure and Injury Mass CasualtyMass Casualty Interfacility TransportsInterfacility Transports RefusalsRefusals

Mass Casualty EventsMass Casualty Events

Documentation may have to be Documentation may have to be postponedpostponed

Follow Local Policy and ProcedureFollow Local Policy and Procedure Comprehensive run report must be Comprehensive run report must be

completed for each patient when completed for each patient when time permitstime permits

Refusal of CareRefusal of Care

Potential for LiabilityPotential for Liability Good DocumentationGood Documentation Make it clearMake it clear

Refusal of CareRefusal of Care

The litigation rate for EMS has been steadily increasing

1048657 According to one study patients evaluatedby paramedics but not transported to thehospital account for 50 to 90 of EMSlawsuitsrdquo

1048657 Documentation is your best defenserdquo

DocumentationDocumentation

Physical FindingsPhysical Findings The advice you give the patient about The advice you give the patient about

being transported and the associated being transported and the associated risks for not being transportedrisks for not being transported

Clinical indications that patient is Clinical indications that patient is competent to make a rational decisioncompetent to make a rational decision

Signatures of the patient and witnessSignatures of the patient and witness Full narrativeFull narrative Advise to call 911 if condition changesAdvise to call 911 if condition changes

Do not at any time attempt to talk the patient out of going to the hospital

If you feel strongly that the patient should be seen make every attempt to convince them they should be seen

Donrsquot say lsquo I agree you donrsquot need to gordquo even if you agree

What not to sayWhat not to say

A patient suffers a diabetic emergency She is treated by the local EMS crew with an A patient suffers a diabetic emergency She is treated by the local EMS crew with an IV an ampule of D50 and transported to the closet hospital despite family members IV an ampule of D50 and transported to the closet hospital despite family members telling you that the patient does not go theretelling you that the patient does not go there

Transport is uneventful and care is turned over to the ED Nurse with a quick verbal Transport is uneventful and care is turned over to the ED Nurse with a quick verbal reportreport

An hour later a private ambulance is called to transport the patient to her desired An hour later a private ambulance is called to transport the patient to her desired hospital for definitive care They notice the IV has infiltrated and D50 got into her hospital for definitive care They notice the IV has infiltrated and D50 got into her surrounding tissuessurrounding tissues

The patient suffers significant tissue damage which requires a fasciotomy to The patient suffers significant tissue damage which requires a fasciotomy to decompress her hand and forearm She has permanent nerve damage and requires decompress her hand and forearm She has permanent nerve damage and requires skin graftingskin grafting

Initial Transport Agency-CFDInitial Transport Agency-CFD

First Receiving Hospital-St Anthony HospitalFirst Receiving Hospital-St Anthony Hospital

Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998

Lets Finish upLets Finish up

Be ProfessionalBe Professional AccurateAccurate ConsistentConsistent ThroughThrough ClearClear BriefBrief Paint the PicturePaint the Picture CollaborativeCollaborative

Legible spelling Legible spelling correctcorrect

Tell the TruthTell the Truth Donrsquot duplicate infoDonrsquot duplicate info Follow ProtocolsFollow Protocols Plain LanguagePlain Language Relevant InformationRelevant Information ldquoldquoThe JURYrdquoThe JURYrdquo Have your partner Have your partner

reviewreview

(A) Assessment(A) Assessment

Include both negative and positive findings Responses the patient has to your

assessment such as the presence or lack of pain andor the presence or lack of sensation

Diagnostic Testing ECG Pulse Oximetry Capnography Blood Glucose Monitoring

(R) Rx-Treatment(R) Rx-Treatment

Document your treatmentDocument your treatment Responses from the Patient to RxResponses from the Patient to Rx Changes in Patients conditionChanges in Patients condition

Example Example ldquoPain decreased to 510 from ldquoPain decreased to 510 from 710 after NTG administered710 after NTG administered

(T) Transport(T) Transport

Where did you goWhere did you go Change in condition during Change in condition during

transporttransport Alteration from ProtocolAlteration from Protocol Who did you turn care over to Who did you turn care over to

(Name if Possible) Ie RN Robinson(Name if Possible) Ie RN Robinson Patency of airway and IV fluidsPatency of airway and IV fluids

CHRONOLOGICALCHRONOLOGICAL

ldquoldquoWrite like your brain thinks itrdquoWrite like your brain thinks itrdquo

Dispatched non-emergent to University Hospitals Dispatched non-emergent to University Hospitals Emergency Educations center for a transport to Emergency Educations center for a transport to UW ER Arrived on floor and met by staff who UW ER Arrived on floor and met by staff who advised us that the patient was suffering from advised us that the patient was suffering from severe PES (Paramedic Education Syndrome) severe PES (Paramedic Education Syndrome) Patient is Mr D a 48 yo male with hx of PES and Patient is Mr D a 48 yo male with hx of PES and CHF who presented with chest pain and CHF who presented with chest pain and dyspneahellipdyspneahellip

Errors and FalsificationsErrors and Falsifications

Avoid ErrorsAvoid Errors Admit when you made a mistakeAdmit when you made a mistake

Revise if necessaryRevise if necessary Note date and time of revisionNote date and time of revision Keep original documentKeep original document Include purpose of the revisionInclude purpose of the revision Only the original author can make the Only the original author can make the

correctioncorrection

Errors and FalsificationsErrors and Falsifications

Always be honest and through in your Always be honest and through in your documentationdocumentation

CorrectionsCorrections Add a supplement on electronic reportsAdd a supplement on electronic reports One line across the error initial the One line across the error initial the

mistake and make the corrections on mistake and make the corrections on written reportswritten reports

Complete reports as soon as possible Complete reports as soon as possible Lost reports have HUGE legal implicationsLost reports have HUGE legal implications Dont keep copies of your reportsDont keep copies of your reports

HIPPAHIPPA

What Happens on What Happens on the Ambulance the Ambulance stays on the stays on the ambulance ambulance

Health Health InsuranceInsurance PortabilityPortability PrivacyPrivacy AccountabilityAccountability

HIPPAHIPPA

Protects the security and privacy of Protects the security and privacy of all medical records and other health all medical records and other health information used or shared in any information used or shared in any formform

Protects patients rights by giving Protects patients rights by giving access to health information and access to health information and control over how it is usedcontrol over how it is used

PHIPHI Protected Heath InformationProtected Heath Information

Information that relates toInformation that relates to The health of an individualThe health of an individual Health care provided to that individualHealth care provided to that individual Payment of heath care providedPayment of heath care provided

What can be sharedWhat can be shared

Health Insurance Company my need Health Insurance Company my need information to process a claiminformation to process a claim

Caregivers involved with direct care Caregivers involved with direct care Quality Assurance when necessaryQuality Assurance when necessary

Special ConsiderationsSpecial Considerations

Exposure and InjuryExposure and Injury Mass CasualtyMass Casualty Interfacility TransportsInterfacility Transports RefusalsRefusals

Mass Casualty EventsMass Casualty Events

Documentation may have to be Documentation may have to be postponedpostponed

Follow Local Policy and ProcedureFollow Local Policy and Procedure Comprehensive run report must be Comprehensive run report must be

completed for each patient when completed for each patient when time permitstime permits

Refusal of CareRefusal of Care

Potential for LiabilityPotential for Liability Good DocumentationGood Documentation Make it clearMake it clear

Refusal of CareRefusal of Care

The litigation rate for EMS has been steadily increasing

1048657 According to one study patients evaluatedby paramedics but not transported to thehospital account for 50 to 90 of EMSlawsuitsrdquo

1048657 Documentation is your best defenserdquo

DocumentationDocumentation

Physical FindingsPhysical Findings The advice you give the patient about The advice you give the patient about

being transported and the associated being transported and the associated risks for not being transportedrisks for not being transported

Clinical indications that patient is Clinical indications that patient is competent to make a rational decisioncompetent to make a rational decision

Signatures of the patient and witnessSignatures of the patient and witness Full narrativeFull narrative Advise to call 911 if condition changesAdvise to call 911 if condition changes

Do not at any time attempt to talk the patient out of going to the hospital

If you feel strongly that the patient should be seen make every attempt to convince them they should be seen

Donrsquot say lsquo I agree you donrsquot need to gordquo even if you agree

What not to sayWhat not to say

A patient suffers a diabetic emergency She is treated by the local EMS crew with an A patient suffers a diabetic emergency She is treated by the local EMS crew with an IV an ampule of D50 and transported to the closet hospital despite family members IV an ampule of D50 and transported to the closet hospital despite family members telling you that the patient does not go theretelling you that the patient does not go there

Transport is uneventful and care is turned over to the ED Nurse with a quick verbal Transport is uneventful and care is turned over to the ED Nurse with a quick verbal reportreport

An hour later a private ambulance is called to transport the patient to her desired An hour later a private ambulance is called to transport the patient to her desired hospital for definitive care They notice the IV has infiltrated and D50 got into her hospital for definitive care They notice the IV has infiltrated and D50 got into her surrounding tissuessurrounding tissues

The patient suffers significant tissue damage which requires a fasciotomy to The patient suffers significant tissue damage which requires a fasciotomy to decompress her hand and forearm She has permanent nerve damage and requires decompress her hand and forearm She has permanent nerve damage and requires skin graftingskin grafting

Initial Transport Agency-CFDInitial Transport Agency-CFD

First Receiving Hospital-St Anthony HospitalFirst Receiving Hospital-St Anthony Hospital

Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998

Lets Finish upLets Finish up

Be ProfessionalBe Professional AccurateAccurate ConsistentConsistent ThroughThrough ClearClear BriefBrief Paint the PicturePaint the Picture CollaborativeCollaborative

Legible spelling Legible spelling correctcorrect

Tell the TruthTell the Truth Donrsquot duplicate infoDonrsquot duplicate info Follow ProtocolsFollow Protocols Plain LanguagePlain Language Relevant InformationRelevant Information ldquoldquoThe JURYrdquoThe JURYrdquo Have your partner Have your partner

reviewreview

(R) Rx-Treatment(R) Rx-Treatment

Document your treatmentDocument your treatment Responses from the Patient to RxResponses from the Patient to Rx Changes in Patients conditionChanges in Patients condition

Example Example ldquoPain decreased to 510 from ldquoPain decreased to 510 from 710 after NTG administered710 after NTG administered

(T) Transport(T) Transport

Where did you goWhere did you go Change in condition during Change in condition during

transporttransport Alteration from ProtocolAlteration from Protocol Who did you turn care over to Who did you turn care over to

(Name if Possible) Ie RN Robinson(Name if Possible) Ie RN Robinson Patency of airway and IV fluidsPatency of airway and IV fluids

CHRONOLOGICALCHRONOLOGICAL

ldquoldquoWrite like your brain thinks itrdquoWrite like your brain thinks itrdquo

Dispatched non-emergent to University Hospitals Dispatched non-emergent to University Hospitals Emergency Educations center for a transport to Emergency Educations center for a transport to UW ER Arrived on floor and met by staff who UW ER Arrived on floor and met by staff who advised us that the patient was suffering from advised us that the patient was suffering from severe PES (Paramedic Education Syndrome) severe PES (Paramedic Education Syndrome) Patient is Mr D a 48 yo male with hx of PES and Patient is Mr D a 48 yo male with hx of PES and CHF who presented with chest pain and CHF who presented with chest pain and dyspneahellipdyspneahellip

Errors and FalsificationsErrors and Falsifications

Avoid ErrorsAvoid Errors Admit when you made a mistakeAdmit when you made a mistake

Revise if necessaryRevise if necessary Note date and time of revisionNote date and time of revision Keep original documentKeep original document Include purpose of the revisionInclude purpose of the revision Only the original author can make the Only the original author can make the

correctioncorrection

Errors and FalsificationsErrors and Falsifications

Always be honest and through in your Always be honest and through in your documentationdocumentation

CorrectionsCorrections Add a supplement on electronic reportsAdd a supplement on electronic reports One line across the error initial the One line across the error initial the

mistake and make the corrections on mistake and make the corrections on written reportswritten reports

Complete reports as soon as possible Complete reports as soon as possible Lost reports have HUGE legal implicationsLost reports have HUGE legal implications Dont keep copies of your reportsDont keep copies of your reports

HIPPAHIPPA

What Happens on What Happens on the Ambulance the Ambulance stays on the stays on the ambulance ambulance

Health Health InsuranceInsurance PortabilityPortability PrivacyPrivacy AccountabilityAccountability

HIPPAHIPPA

Protects the security and privacy of Protects the security and privacy of all medical records and other health all medical records and other health information used or shared in any information used or shared in any formform

Protects patients rights by giving Protects patients rights by giving access to health information and access to health information and control over how it is usedcontrol over how it is used

PHIPHI Protected Heath InformationProtected Heath Information

Information that relates toInformation that relates to The health of an individualThe health of an individual Health care provided to that individualHealth care provided to that individual Payment of heath care providedPayment of heath care provided

What can be sharedWhat can be shared

Health Insurance Company my need Health Insurance Company my need information to process a claiminformation to process a claim

Caregivers involved with direct care Caregivers involved with direct care Quality Assurance when necessaryQuality Assurance when necessary

Special ConsiderationsSpecial Considerations

Exposure and InjuryExposure and Injury Mass CasualtyMass Casualty Interfacility TransportsInterfacility Transports RefusalsRefusals

Mass Casualty EventsMass Casualty Events

Documentation may have to be Documentation may have to be postponedpostponed

Follow Local Policy and ProcedureFollow Local Policy and Procedure Comprehensive run report must be Comprehensive run report must be

completed for each patient when completed for each patient when time permitstime permits

Refusal of CareRefusal of Care

Potential for LiabilityPotential for Liability Good DocumentationGood Documentation Make it clearMake it clear

Refusal of CareRefusal of Care

The litigation rate for EMS has been steadily increasing

1048657 According to one study patients evaluatedby paramedics but not transported to thehospital account for 50 to 90 of EMSlawsuitsrdquo

1048657 Documentation is your best defenserdquo

DocumentationDocumentation

Physical FindingsPhysical Findings The advice you give the patient about The advice you give the patient about

being transported and the associated being transported and the associated risks for not being transportedrisks for not being transported

Clinical indications that patient is Clinical indications that patient is competent to make a rational decisioncompetent to make a rational decision

Signatures of the patient and witnessSignatures of the patient and witness Full narrativeFull narrative Advise to call 911 if condition changesAdvise to call 911 if condition changes

Do not at any time attempt to talk the patient out of going to the hospital

If you feel strongly that the patient should be seen make every attempt to convince them they should be seen

Donrsquot say lsquo I agree you donrsquot need to gordquo even if you agree

What not to sayWhat not to say

A patient suffers a diabetic emergency She is treated by the local EMS crew with an A patient suffers a diabetic emergency She is treated by the local EMS crew with an IV an ampule of D50 and transported to the closet hospital despite family members IV an ampule of D50 and transported to the closet hospital despite family members telling you that the patient does not go theretelling you that the patient does not go there

Transport is uneventful and care is turned over to the ED Nurse with a quick verbal Transport is uneventful and care is turned over to the ED Nurse with a quick verbal reportreport

An hour later a private ambulance is called to transport the patient to her desired An hour later a private ambulance is called to transport the patient to her desired hospital for definitive care They notice the IV has infiltrated and D50 got into her hospital for definitive care They notice the IV has infiltrated and D50 got into her surrounding tissuessurrounding tissues

The patient suffers significant tissue damage which requires a fasciotomy to The patient suffers significant tissue damage which requires a fasciotomy to decompress her hand and forearm She has permanent nerve damage and requires decompress her hand and forearm She has permanent nerve damage and requires skin graftingskin grafting

Initial Transport Agency-CFDInitial Transport Agency-CFD

First Receiving Hospital-St Anthony HospitalFirst Receiving Hospital-St Anthony Hospital

Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998

Lets Finish upLets Finish up

Be ProfessionalBe Professional AccurateAccurate ConsistentConsistent ThroughThrough ClearClear BriefBrief Paint the PicturePaint the Picture CollaborativeCollaborative

Legible spelling Legible spelling correctcorrect

Tell the TruthTell the Truth Donrsquot duplicate infoDonrsquot duplicate info Follow ProtocolsFollow Protocols Plain LanguagePlain Language Relevant InformationRelevant Information ldquoldquoThe JURYrdquoThe JURYrdquo Have your partner Have your partner

reviewreview

(T) Transport(T) Transport

Where did you goWhere did you go Change in condition during Change in condition during

transporttransport Alteration from ProtocolAlteration from Protocol Who did you turn care over to Who did you turn care over to

(Name if Possible) Ie RN Robinson(Name if Possible) Ie RN Robinson Patency of airway and IV fluidsPatency of airway and IV fluids

CHRONOLOGICALCHRONOLOGICAL

ldquoldquoWrite like your brain thinks itrdquoWrite like your brain thinks itrdquo

Dispatched non-emergent to University Hospitals Dispatched non-emergent to University Hospitals Emergency Educations center for a transport to Emergency Educations center for a transport to UW ER Arrived on floor and met by staff who UW ER Arrived on floor and met by staff who advised us that the patient was suffering from advised us that the patient was suffering from severe PES (Paramedic Education Syndrome) severe PES (Paramedic Education Syndrome) Patient is Mr D a 48 yo male with hx of PES and Patient is Mr D a 48 yo male with hx of PES and CHF who presented with chest pain and CHF who presented with chest pain and dyspneahellipdyspneahellip

Errors and FalsificationsErrors and Falsifications

Avoid ErrorsAvoid Errors Admit when you made a mistakeAdmit when you made a mistake

Revise if necessaryRevise if necessary Note date and time of revisionNote date and time of revision Keep original documentKeep original document Include purpose of the revisionInclude purpose of the revision Only the original author can make the Only the original author can make the

correctioncorrection

Errors and FalsificationsErrors and Falsifications

Always be honest and through in your Always be honest and through in your documentationdocumentation

CorrectionsCorrections Add a supplement on electronic reportsAdd a supplement on electronic reports One line across the error initial the One line across the error initial the

mistake and make the corrections on mistake and make the corrections on written reportswritten reports

Complete reports as soon as possible Complete reports as soon as possible Lost reports have HUGE legal implicationsLost reports have HUGE legal implications Dont keep copies of your reportsDont keep copies of your reports

HIPPAHIPPA

What Happens on What Happens on the Ambulance the Ambulance stays on the stays on the ambulance ambulance

Health Health InsuranceInsurance PortabilityPortability PrivacyPrivacy AccountabilityAccountability

HIPPAHIPPA

Protects the security and privacy of Protects the security and privacy of all medical records and other health all medical records and other health information used or shared in any information used or shared in any formform

Protects patients rights by giving Protects patients rights by giving access to health information and access to health information and control over how it is usedcontrol over how it is used

PHIPHI Protected Heath InformationProtected Heath Information

Information that relates toInformation that relates to The health of an individualThe health of an individual Health care provided to that individualHealth care provided to that individual Payment of heath care providedPayment of heath care provided

What can be sharedWhat can be shared

Health Insurance Company my need Health Insurance Company my need information to process a claiminformation to process a claim

Caregivers involved with direct care Caregivers involved with direct care Quality Assurance when necessaryQuality Assurance when necessary

Special ConsiderationsSpecial Considerations

Exposure and InjuryExposure and Injury Mass CasualtyMass Casualty Interfacility TransportsInterfacility Transports RefusalsRefusals

Mass Casualty EventsMass Casualty Events

Documentation may have to be Documentation may have to be postponedpostponed

Follow Local Policy and ProcedureFollow Local Policy and Procedure Comprehensive run report must be Comprehensive run report must be

completed for each patient when completed for each patient when time permitstime permits

Refusal of CareRefusal of Care

Potential for LiabilityPotential for Liability Good DocumentationGood Documentation Make it clearMake it clear

Refusal of CareRefusal of Care

The litigation rate for EMS has been steadily increasing

1048657 According to one study patients evaluatedby paramedics but not transported to thehospital account for 50 to 90 of EMSlawsuitsrdquo

1048657 Documentation is your best defenserdquo

DocumentationDocumentation

Physical FindingsPhysical Findings The advice you give the patient about The advice you give the patient about

being transported and the associated being transported and the associated risks for not being transportedrisks for not being transported

Clinical indications that patient is Clinical indications that patient is competent to make a rational decisioncompetent to make a rational decision

Signatures of the patient and witnessSignatures of the patient and witness Full narrativeFull narrative Advise to call 911 if condition changesAdvise to call 911 if condition changes

Do not at any time attempt to talk the patient out of going to the hospital

If you feel strongly that the patient should be seen make every attempt to convince them they should be seen

Donrsquot say lsquo I agree you donrsquot need to gordquo even if you agree

What not to sayWhat not to say

A patient suffers a diabetic emergency She is treated by the local EMS crew with an A patient suffers a diabetic emergency She is treated by the local EMS crew with an IV an ampule of D50 and transported to the closet hospital despite family members IV an ampule of D50 and transported to the closet hospital despite family members telling you that the patient does not go theretelling you that the patient does not go there

Transport is uneventful and care is turned over to the ED Nurse with a quick verbal Transport is uneventful and care is turned over to the ED Nurse with a quick verbal reportreport

An hour later a private ambulance is called to transport the patient to her desired An hour later a private ambulance is called to transport the patient to her desired hospital for definitive care They notice the IV has infiltrated and D50 got into her hospital for definitive care They notice the IV has infiltrated and D50 got into her surrounding tissuessurrounding tissues

The patient suffers significant tissue damage which requires a fasciotomy to The patient suffers significant tissue damage which requires a fasciotomy to decompress her hand and forearm She has permanent nerve damage and requires decompress her hand and forearm She has permanent nerve damage and requires skin graftingskin grafting

Initial Transport Agency-CFDInitial Transport Agency-CFD

First Receiving Hospital-St Anthony HospitalFirst Receiving Hospital-St Anthony Hospital

Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998

Lets Finish upLets Finish up

Be ProfessionalBe Professional AccurateAccurate ConsistentConsistent ThroughThrough ClearClear BriefBrief Paint the PicturePaint the Picture CollaborativeCollaborative

Legible spelling Legible spelling correctcorrect

Tell the TruthTell the Truth Donrsquot duplicate infoDonrsquot duplicate info Follow ProtocolsFollow Protocols Plain LanguagePlain Language Relevant InformationRelevant Information ldquoldquoThe JURYrdquoThe JURYrdquo Have your partner Have your partner

reviewreview

CHRONOLOGICALCHRONOLOGICAL

ldquoldquoWrite like your brain thinks itrdquoWrite like your brain thinks itrdquo

Dispatched non-emergent to University Hospitals Dispatched non-emergent to University Hospitals Emergency Educations center for a transport to Emergency Educations center for a transport to UW ER Arrived on floor and met by staff who UW ER Arrived on floor and met by staff who advised us that the patient was suffering from advised us that the patient was suffering from severe PES (Paramedic Education Syndrome) severe PES (Paramedic Education Syndrome) Patient is Mr D a 48 yo male with hx of PES and Patient is Mr D a 48 yo male with hx of PES and CHF who presented with chest pain and CHF who presented with chest pain and dyspneahellipdyspneahellip

Errors and FalsificationsErrors and Falsifications

Avoid ErrorsAvoid Errors Admit when you made a mistakeAdmit when you made a mistake

Revise if necessaryRevise if necessary Note date and time of revisionNote date and time of revision Keep original documentKeep original document Include purpose of the revisionInclude purpose of the revision Only the original author can make the Only the original author can make the

correctioncorrection

Errors and FalsificationsErrors and Falsifications

Always be honest and through in your Always be honest and through in your documentationdocumentation

CorrectionsCorrections Add a supplement on electronic reportsAdd a supplement on electronic reports One line across the error initial the One line across the error initial the

mistake and make the corrections on mistake and make the corrections on written reportswritten reports

Complete reports as soon as possible Complete reports as soon as possible Lost reports have HUGE legal implicationsLost reports have HUGE legal implications Dont keep copies of your reportsDont keep copies of your reports

HIPPAHIPPA

What Happens on What Happens on the Ambulance the Ambulance stays on the stays on the ambulance ambulance

Health Health InsuranceInsurance PortabilityPortability PrivacyPrivacy AccountabilityAccountability

HIPPAHIPPA

Protects the security and privacy of Protects the security and privacy of all medical records and other health all medical records and other health information used or shared in any information used or shared in any formform

Protects patients rights by giving Protects patients rights by giving access to health information and access to health information and control over how it is usedcontrol over how it is used

PHIPHI Protected Heath InformationProtected Heath Information

Information that relates toInformation that relates to The health of an individualThe health of an individual Health care provided to that individualHealth care provided to that individual Payment of heath care providedPayment of heath care provided

What can be sharedWhat can be shared

Health Insurance Company my need Health Insurance Company my need information to process a claiminformation to process a claim

Caregivers involved with direct care Caregivers involved with direct care Quality Assurance when necessaryQuality Assurance when necessary

Special ConsiderationsSpecial Considerations

Exposure and InjuryExposure and Injury Mass CasualtyMass Casualty Interfacility TransportsInterfacility Transports RefusalsRefusals

Mass Casualty EventsMass Casualty Events

Documentation may have to be Documentation may have to be postponedpostponed

Follow Local Policy and ProcedureFollow Local Policy and Procedure Comprehensive run report must be Comprehensive run report must be

completed for each patient when completed for each patient when time permitstime permits

Refusal of CareRefusal of Care

Potential for LiabilityPotential for Liability Good DocumentationGood Documentation Make it clearMake it clear

Refusal of CareRefusal of Care

The litigation rate for EMS has been steadily increasing

1048657 According to one study patients evaluatedby paramedics but not transported to thehospital account for 50 to 90 of EMSlawsuitsrdquo

1048657 Documentation is your best defenserdquo

DocumentationDocumentation

Physical FindingsPhysical Findings The advice you give the patient about The advice you give the patient about

being transported and the associated being transported and the associated risks for not being transportedrisks for not being transported

Clinical indications that patient is Clinical indications that patient is competent to make a rational decisioncompetent to make a rational decision

Signatures of the patient and witnessSignatures of the patient and witness Full narrativeFull narrative Advise to call 911 if condition changesAdvise to call 911 if condition changes

Do not at any time attempt to talk the patient out of going to the hospital

If you feel strongly that the patient should be seen make every attempt to convince them they should be seen

Donrsquot say lsquo I agree you donrsquot need to gordquo even if you agree

What not to sayWhat not to say

A patient suffers a diabetic emergency She is treated by the local EMS crew with an A patient suffers a diabetic emergency She is treated by the local EMS crew with an IV an ampule of D50 and transported to the closet hospital despite family members IV an ampule of D50 and transported to the closet hospital despite family members telling you that the patient does not go theretelling you that the patient does not go there

Transport is uneventful and care is turned over to the ED Nurse with a quick verbal Transport is uneventful and care is turned over to the ED Nurse with a quick verbal reportreport

An hour later a private ambulance is called to transport the patient to her desired An hour later a private ambulance is called to transport the patient to her desired hospital for definitive care They notice the IV has infiltrated and D50 got into her hospital for definitive care They notice the IV has infiltrated and D50 got into her surrounding tissuessurrounding tissues

The patient suffers significant tissue damage which requires a fasciotomy to The patient suffers significant tissue damage which requires a fasciotomy to decompress her hand and forearm She has permanent nerve damage and requires decompress her hand and forearm She has permanent nerve damage and requires skin graftingskin grafting

Initial Transport Agency-CFDInitial Transport Agency-CFD

First Receiving Hospital-St Anthony HospitalFirst Receiving Hospital-St Anthony Hospital

Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998

Lets Finish upLets Finish up

Be ProfessionalBe Professional AccurateAccurate ConsistentConsistent ThroughThrough ClearClear BriefBrief Paint the PicturePaint the Picture CollaborativeCollaborative

Legible spelling Legible spelling correctcorrect

Tell the TruthTell the Truth Donrsquot duplicate infoDonrsquot duplicate info Follow ProtocolsFollow Protocols Plain LanguagePlain Language Relevant InformationRelevant Information ldquoldquoThe JURYrdquoThe JURYrdquo Have your partner Have your partner

reviewreview

Errors and FalsificationsErrors and Falsifications

Avoid ErrorsAvoid Errors Admit when you made a mistakeAdmit when you made a mistake

Revise if necessaryRevise if necessary Note date and time of revisionNote date and time of revision Keep original documentKeep original document Include purpose of the revisionInclude purpose of the revision Only the original author can make the Only the original author can make the

correctioncorrection

Errors and FalsificationsErrors and Falsifications

Always be honest and through in your Always be honest and through in your documentationdocumentation

CorrectionsCorrections Add a supplement on electronic reportsAdd a supplement on electronic reports One line across the error initial the One line across the error initial the

mistake and make the corrections on mistake and make the corrections on written reportswritten reports

Complete reports as soon as possible Complete reports as soon as possible Lost reports have HUGE legal implicationsLost reports have HUGE legal implications Dont keep copies of your reportsDont keep copies of your reports

HIPPAHIPPA

What Happens on What Happens on the Ambulance the Ambulance stays on the stays on the ambulance ambulance

Health Health InsuranceInsurance PortabilityPortability PrivacyPrivacy AccountabilityAccountability

HIPPAHIPPA

Protects the security and privacy of Protects the security and privacy of all medical records and other health all medical records and other health information used or shared in any information used or shared in any formform

Protects patients rights by giving Protects patients rights by giving access to health information and access to health information and control over how it is usedcontrol over how it is used

PHIPHI Protected Heath InformationProtected Heath Information

Information that relates toInformation that relates to The health of an individualThe health of an individual Health care provided to that individualHealth care provided to that individual Payment of heath care providedPayment of heath care provided

What can be sharedWhat can be shared

Health Insurance Company my need Health Insurance Company my need information to process a claiminformation to process a claim

Caregivers involved with direct care Caregivers involved with direct care Quality Assurance when necessaryQuality Assurance when necessary

Special ConsiderationsSpecial Considerations

Exposure and InjuryExposure and Injury Mass CasualtyMass Casualty Interfacility TransportsInterfacility Transports RefusalsRefusals

Mass Casualty EventsMass Casualty Events

Documentation may have to be Documentation may have to be postponedpostponed

Follow Local Policy and ProcedureFollow Local Policy and Procedure Comprehensive run report must be Comprehensive run report must be

completed for each patient when completed for each patient when time permitstime permits

Refusal of CareRefusal of Care

Potential for LiabilityPotential for Liability Good DocumentationGood Documentation Make it clearMake it clear

Refusal of CareRefusal of Care

The litigation rate for EMS has been steadily increasing

1048657 According to one study patients evaluatedby paramedics but not transported to thehospital account for 50 to 90 of EMSlawsuitsrdquo

1048657 Documentation is your best defenserdquo

DocumentationDocumentation

Physical FindingsPhysical Findings The advice you give the patient about The advice you give the patient about

being transported and the associated being transported and the associated risks for not being transportedrisks for not being transported

Clinical indications that patient is Clinical indications that patient is competent to make a rational decisioncompetent to make a rational decision

Signatures of the patient and witnessSignatures of the patient and witness Full narrativeFull narrative Advise to call 911 if condition changesAdvise to call 911 if condition changes

Do not at any time attempt to talk the patient out of going to the hospital

If you feel strongly that the patient should be seen make every attempt to convince them they should be seen

Donrsquot say lsquo I agree you donrsquot need to gordquo even if you agree

What not to sayWhat not to say

A patient suffers a diabetic emergency She is treated by the local EMS crew with an A patient suffers a diabetic emergency She is treated by the local EMS crew with an IV an ampule of D50 and transported to the closet hospital despite family members IV an ampule of D50 and transported to the closet hospital despite family members telling you that the patient does not go theretelling you that the patient does not go there

Transport is uneventful and care is turned over to the ED Nurse with a quick verbal Transport is uneventful and care is turned over to the ED Nurse with a quick verbal reportreport

An hour later a private ambulance is called to transport the patient to her desired An hour later a private ambulance is called to transport the patient to her desired hospital for definitive care They notice the IV has infiltrated and D50 got into her hospital for definitive care They notice the IV has infiltrated and D50 got into her surrounding tissuessurrounding tissues

The patient suffers significant tissue damage which requires a fasciotomy to The patient suffers significant tissue damage which requires a fasciotomy to decompress her hand and forearm She has permanent nerve damage and requires decompress her hand and forearm She has permanent nerve damage and requires skin graftingskin grafting

Initial Transport Agency-CFDInitial Transport Agency-CFD

First Receiving Hospital-St Anthony HospitalFirst Receiving Hospital-St Anthony Hospital

Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998

Lets Finish upLets Finish up

Be ProfessionalBe Professional AccurateAccurate ConsistentConsistent ThroughThrough ClearClear BriefBrief Paint the PicturePaint the Picture CollaborativeCollaborative

Legible spelling Legible spelling correctcorrect

Tell the TruthTell the Truth Donrsquot duplicate infoDonrsquot duplicate info Follow ProtocolsFollow Protocols Plain LanguagePlain Language Relevant InformationRelevant Information ldquoldquoThe JURYrdquoThe JURYrdquo Have your partner Have your partner

reviewreview

Errors and FalsificationsErrors and Falsifications

Always be honest and through in your Always be honest and through in your documentationdocumentation

CorrectionsCorrections Add a supplement on electronic reportsAdd a supplement on electronic reports One line across the error initial the One line across the error initial the

mistake and make the corrections on mistake and make the corrections on written reportswritten reports

Complete reports as soon as possible Complete reports as soon as possible Lost reports have HUGE legal implicationsLost reports have HUGE legal implications Dont keep copies of your reportsDont keep copies of your reports

HIPPAHIPPA

What Happens on What Happens on the Ambulance the Ambulance stays on the stays on the ambulance ambulance

Health Health InsuranceInsurance PortabilityPortability PrivacyPrivacy AccountabilityAccountability

HIPPAHIPPA

Protects the security and privacy of Protects the security and privacy of all medical records and other health all medical records and other health information used or shared in any information used or shared in any formform

Protects patients rights by giving Protects patients rights by giving access to health information and access to health information and control over how it is usedcontrol over how it is used

PHIPHI Protected Heath InformationProtected Heath Information

Information that relates toInformation that relates to The health of an individualThe health of an individual Health care provided to that individualHealth care provided to that individual Payment of heath care providedPayment of heath care provided

What can be sharedWhat can be shared

Health Insurance Company my need Health Insurance Company my need information to process a claiminformation to process a claim

Caregivers involved with direct care Caregivers involved with direct care Quality Assurance when necessaryQuality Assurance when necessary

Special ConsiderationsSpecial Considerations

Exposure and InjuryExposure and Injury Mass CasualtyMass Casualty Interfacility TransportsInterfacility Transports RefusalsRefusals

Mass Casualty EventsMass Casualty Events

Documentation may have to be Documentation may have to be postponedpostponed

Follow Local Policy and ProcedureFollow Local Policy and Procedure Comprehensive run report must be Comprehensive run report must be

completed for each patient when completed for each patient when time permitstime permits

Refusal of CareRefusal of Care

Potential for LiabilityPotential for Liability Good DocumentationGood Documentation Make it clearMake it clear

Refusal of CareRefusal of Care

The litigation rate for EMS has been steadily increasing

1048657 According to one study patients evaluatedby paramedics but not transported to thehospital account for 50 to 90 of EMSlawsuitsrdquo

1048657 Documentation is your best defenserdquo

DocumentationDocumentation

Physical FindingsPhysical Findings The advice you give the patient about The advice you give the patient about

being transported and the associated being transported and the associated risks for not being transportedrisks for not being transported

Clinical indications that patient is Clinical indications that patient is competent to make a rational decisioncompetent to make a rational decision

Signatures of the patient and witnessSignatures of the patient and witness Full narrativeFull narrative Advise to call 911 if condition changesAdvise to call 911 if condition changes

Do not at any time attempt to talk the patient out of going to the hospital

If you feel strongly that the patient should be seen make every attempt to convince them they should be seen

Donrsquot say lsquo I agree you donrsquot need to gordquo even if you agree

What not to sayWhat not to say

A patient suffers a diabetic emergency She is treated by the local EMS crew with an A patient suffers a diabetic emergency She is treated by the local EMS crew with an IV an ampule of D50 and transported to the closet hospital despite family members IV an ampule of D50 and transported to the closet hospital despite family members telling you that the patient does not go theretelling you that the patient does not go there

Transport is uneventful and care is turned over to the ED Nurse with a quick verbal Transport is uneventful and care is turned over to the ED Nurse with a quick verbal reportreport

An hour later a private ambulance is called to transport the patient to her desired An hour later a private ambulance is called to transport the patient to her desired hospital for definitive care They notice the IV has infiltrated and D50 got into her hospital for definitive care They notice the IV has infiltrated and D50 got into her surrounding tissuessurrounding tissues

The patient suffers significant tissue damage which requires a fasciotomy to The patient suffers significant tissue damage which requires a fasciotomy to decompress her hand and forearm She has permanent nerve damage and requires decompress her hand and forearm She has permanent nerve damage and requires skin graftingskin grafting

Initial Transport Agency-CFDInitial Transport Agency-CFD

First Receiving Hospital-St Anthony HospitalFirst Receiving Hospital-St Anthony Hospital

Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998

Lets Finish upLets Finish up

Be ProfessionalBe Professional AccurateAccurate ConsistentConsistent ThroughThrough ClearClear BriefBrief Paint the PicturePaint the Picture CollaborativeCollaborative

Legible spelling Legible spelling correctcorrect

Tell the TruthTell the Truth Donrsquot duplicate infoDonrsquot duplicate info Follow ProtocolsFollow Protocols Plain LanguagePlain Language Relevant InformationRelevant Information ldquoldquoThe JURYrdquoThe JURYrdquo Have your partner Have your partner

reviewreview

HIPPAHIPPA

What Happens on What Happens on the Ambulance the Ambulance stays on the stays on the ambulance ambulance

Health Health InsuranceInsurance PortabilityPortability PrivacyPrivacy AccountabilityAccountability

HIPPAHIPPA

Protects the security and privacy of Protects the security and privacy of all medical records and other health all medical records and other health information used or shared in any information used or shared in any formform

Protects patients rights by giving Protects patients rights by giving access to health information and access to health information and control over how it is usedcontrol over how it is used

PHIPHI Protected Heath InformationProtected Heath Information

Information that relates toInformation that relates to The health of an individualThe health of an individual Health care provided to that individualHealth care provided to that individual Payment of heath care providedPayment of heath care provided

What can be sharedWhat can be shared

Health Insurance Company my need Health Insurance Company my need information to process a claiminformation to process a claim

Caregivers involved with direct care Caregivers involved with direct care Quality Assurance when necessaryQuality Assurance when necessary

Special ConsiderationsSpecial Considerations

Exposure and InjuryExposure and Injury Mass CasualtyMass Casualty Interfacility TransportsInterfacility Transports RefusalsRefusals

Mass Casualty EventsMass Casualty Events

Documentation may have to be Documentation may have to be postponedpostponed

Follow Local Policy and ProcedureFollow Local Policy and Procedure Comprehensive run report must be Comprehensive run report must be

completed for each patient when completed for each patient when time permitstime permits

Refusal of CareRefusal of Care

Potential for LiabilityPotential for Liability Good DocumentationGood Documentation Make it clearMake it clear

Refusal of CareRefusal of Care

The litigation rate for EMS has been steadily increasing

1048657 According to one study patients evaluatedby paramedics but not transported to thehospital account for 50 to 90 of EMSlawsuitsrdquo

1048657 Documentation is your best defenserdquo

DocumentationDocumentation

Physical FindingsPhysical Findings The advice you give the patient about The advice you give the patient about

being transported and the associated being transported and the associated risks for not being transportedrisks for not being transported

Clinical indications that patient is Clinical indications that patient is competent to make a rational decisioncompetent to make a rational decision

Signatures of the patient and witnessSignatures of the patient and witness Full narrativeFull narrative Advise to call 911 if condition changesAdvise to call 911 if condition changes

Do not at any time attempt to talk the patient out of going to the hospital

If you feel strongly that the patient should be seen make every attempt to convince them they should be seen

Donrsquot say lsquo I agree you donrsquot need to gordquo even if you agree

What not to sayWhat not to say

A patient suffers a diabetic emergency She is treated by the local EMS crew with an A patient suffers a diabetic emergency She is treated by the local EMS crew with an IV an ampule of D50 and transported to the closet hospital despite family members IV an ampule of D50 and transported to the closet hospital despite family members telling you that the patient does not go theretelling you that the patient does not go there

Transport is uneventful and care is turned over to the ED Nurse with a quick verbal Transport is uneventful and care is turned over to the ED Nurse with a quick verbal reportreport

An hour later a private ambulance is called to transport the patient to her desired An hour later a private ambulance is called to transport the patient to her desired hospital for definitive care They notice the IV has infiltrated and D50 got into her hospital for definitive care They notice the IV has infiltrated and D50 got into her surrounding tissuessurrounding tissues

The patient suffers significant tissue damage which requires a fasciotomy to The patient suffers significant tissue damage which requires a fasciotomy to decompress her hand and forearm She has permanent nerve damage and requires decompress her hand and forearm She has permanent nerve damage and requires skin graftingskin grafting

Initial Transport Agency-CFDInitial Transport Agency-CFD

First Receiving Hospital-St Anthony HospitalFirst Receiving Hospital-St Anthony Hospital

Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998

Lets Finish upLets Finish up

Be ProfessionalBe Professional AccurateAccurate ConsistentConsistent ThroughThrough ClearClear BriefBrief Paint the PicturePaint the Picture CollaborativeCollaborative

Legible spelling Legible spelling correctcorrect

Tell the TruthTell the Truth Donrsquot duplicate infoDonrsquot duplicate info Follow ProtocolsFollow Protocols Plain LanguagePlain Language Relevant InformationRelevant Information ldquoldquoThe JURYrdquoThe JURYrdquo Have your partner Have your partner

reviewreview

HIPPAHIPPA

Protects the security and privacy of Protects the security and privacy of all medical records and other health all medical records and other health information used or shared in any information used or shared in any formform

Protects patients rights by giving Protects patients rights by giving access to health information and access to health information and control over how it is usedcontrol over how it is used

PHIPHI Protected Heath InformationProtected Heath Information

Information that relates toInformation that relates to The health of an individualThe health of an individual Health care provided to that individualHealth care provided to that individual Payment of heath care providedPayment of heath care provided

What can be sharedWhat can be shared

Health Insurance Company my need Health Insurance Company my need information to process a claiminformation to process a claim

Caregivers involved with direct care Caregivers involved with direct care Quality Assurance when necessaryQuality Assurance when necessary

Special ConsiderationsSpecial Considerations

Exposure and InjuryExposure and Injury Mass CasualtyMass Casualty Interfacility TransportsInterfacility Transports RefusalsRefusals

Mass Casualty EventsMass Casualty Events

Documentation may have to be Documentation may have to be postponedpostponed

Follow Local Policy and ProcedureFollow Local Policy and Procedure Comprehensive run report must be Comprehensive run report must be

completed for each patient when completed for each patient when time permitstime permits

Refusal of CareRefusal of Care

Potential for LiabilityPotential for Liability Good DocumentationGood Documentation Make it clearMake it clear

Refusal of CareRefusal of Care

The litigation rate for EMS has been steadily increasing

1048657 According to one study patients evaluatedby paramedics but not transported to thehospital account for 50 to 90 of EMSlawsuitsrdquo

1048657 Documentation is your best defenserdquo

DocumentationDocumentation

Physical FindingsPhysical Findings The advice you give the patient about The advice you give the patient about

being transported and the associated being transported and the associated risks for not being transportedrisks for not being transported

Clinical indications that patient is Clinical indications that patient is competent to make a rational decisioncompetent to make a rational decision

Signatures of the patient and witnessSignatures of the patient and witness Full narrativeFull narrative Advise to call 911 if condition changesAdvise to call 911 if condition changes

Do not at any time attempt to talk the patient out of going to the hospital

If you feel strongly that the patient should be seen make every attempt to convince them they should be seen

Donrsquot say lsquo I agree you donrsquot need to gordquo even if you agree

What not to sayWhat not to say

A patient suffers a diabetic emergency She is treated by the local EMS crew with an A patient suffers a diabetic emergency She is treated by the local EMS crew with an IV an ampule of D50 and transported to the closet hospital despite family members IV an ampule of D50 and transported to the closet hospital despite family members telling you that the patient does not go theretelling you that the patient does not go there

Transport is uneventful and care is turned over to the ED Nurse with a quick verbal Transport is uneventful and care is turned over to the ED Nurse with a quick verbal reportreport

An hour later a private ambulance is called to transport the patient to her desired An hour later a private ambulance is called to transport the patient to her desired hospital for definitive care They notice the IV has infiltrated and D50 got into her hospital for definitive care They notice the IV has infiltrated and D50 got into her surrounding tissuessurrounding tissues

The patient suffers significant tissue damage which requires a fasciotomy to The patient suffers significant tissue damage which requires a fasciotomy to decompress her hand and forearm She has permanent nerve damage and requires decompress her hand and forearm She has permanent nerve damage and requires skin graftingskin grafting

Initial Transport Agency-CFDInitial Transport Agency-CFD

First Receiving Hospital-St Anthony HospitalFirst Receiving Hospital-St Anthony Hospital

Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998

Lets Finish upLets Finish up

Be ProfessionalBe Professional AccurateAccurate ConsistentConsistent ThroughThrough ClearClear BriefBrief Paint the PicturePaint the Picture CollaborativeCollaborative

Legible spelling Legible spelling correctcorrect

Tell the TruthTell the Truth Donrsquot duplicate infoDonrsquot duplicate info Follow ProtocolsFollow Protocols Plain LanguagePlain Language Relevant InformationRelevant Information ldquoldquoThe JURYrdquoThe JURYrdquo Have your partner Have your partner

reviewreview

PHIPHI Protected Heath InformationProtected Heath Information

Information that relates toInformation that relates to The health of an individualThe health of an individual Health care provided to that individualHealth care provided to that individual Payment of heath care providedPayment of heath care provided

What can be sharedWhat can be shared

Health Insurance Company my need Health Insurance Company my need information to process a claiminformation to process a claim

Caregivers involved with direct care Caregivers involved with direct care Quality Assurance when necessaryQuality Assurance when necessary

Special ConsiderationsSpecial Considerations

Exposure and InjuryExposure and Injury Mass CasualtyMass Casualty Interfacility TransportsInterfacility Transports RefusalsRefusals

Mass Casualty EventsMass Casualty Events

Documentation may have to be Documentation may have to be postponedpostponed

Follow Local Policy and ProcedureFollow Local Policy and Procedure Comprehensive run report must be Comprehensive run report must be

completed for each patient when completed for each patient when time permitstime permits

Refusal of CareRefusal of Care

Potential for LiabilityPotential for Liability Good DocumentationGood Documentation Make it clearMake it clear

Refusal of CareRefusal of Care

The litigation rate for EMS has been steadily increasing

1048657 According to one study patients evaluatedby paramedics but not transported to thehospital account for 50 to 90 of EMSlawsuitsrdquo

1048657 Documentation is your best defenserdquo

DocumentationDocumentation

Physical FindingsPhysical Findings The advice you give the patient about The advice you give the patient about

being transported and the associated being transported and the associated risks for not being transportedrisks for not being transported

Clinical indications that patient is Clinical indications that patient is competent to make a rational decisioncompetent to make a rational decision

Signatures of the patient and witnessSignatures of the patient and witness Full narrativeFull narrative Advise to call 911 if condition changesAdvise to call 911 if condition changes

Do not at any time attempt to talk the patient out of going to the hospital

If you feel strongly that the patient should be seen make every attempt to convince them they should be seen

Donrsquot say lsquo I agree you donrsquot need to gordquo even if you agree

What not to sayWhat not to say

A patient suffers a diabetic emergency She is treated by the local EMS crew with an A patient suffers a diabetic emergency She is treated by the local EMS crew with an IV an ampule of D50 and transported to the closet hospital despite family members IV an ampule of D50 and transported to the closet hospital despite family members telling you that the patient does not go theretelling you that the patient does not go there

Transport is uneventful and care is turned over to the ED Nurse with a quick verbal Transport is uneventful and care is turned over to the ED Nurse with a quick verbal reportreport

An hour later a private ambulance is called to transport the patient to her desired An hour later a private ambulance is called to transport the patient to her desired hospital for definitive care They notice the IV has infiltrated and D50 got into her hospital for definitive care They notice the IV has infiltrated and D50 got into her surrounding tissuessurrounding tissues

The patient suffers significant tissue damage which requires a fasciotomy to The patient suffers significant tissue damage which requires a fasciotomy to decompress her hand and forearm She has permanent nerve damage and requires decompress her hand and forearm She has permanent nerve damage and requires skin graftingskin grafting

Initial Transport Agency-CFDInitial Transport Agency-CFD

First Receiving Hospital-St Anthony HospitalFirst Receiving Hospital-St Anthony Hospital

Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998

Lets Finish upLets Finish up

Be ProfessionalBe Professional AccurateAccurate ConsistentConsistent ThroughThrough ClearClear BriefBrief Paint the PicturePaint the Picture CollaborativeCollaborative

Legible spelling Legible spelling correctcorrect

Tell the TruthTell the Truth Donrsquot duplicate infoDonrsquot duplicate info Follow ProtocolsFollow Protocols Plain LanguagePlain Language Relevant InformationRelevant Information ldquoldquoThe JURYrdquoThe JURYrdquo Have your partner Have your partner

reviewreview

What can be sharedWhat can be shared

Health Insurance Company my need Health Insurance Company my need information to process a claiminformation to process a claim

Caregivers involved with direct care Caregivers involved with direct care Quality Assurance when necessaryQuality Assurance when necessary

Special ConsiderationsSpecial Considerations

Exposure and InjuryExposure and Injury Mass CasualtyMass Casualty Interfacility TransportsInterfacility Transports RefusalsRefusals

Mass Casualty EventsMass Casualty Events

Documentation may have to be Documentation may have to be postponedpostponed

Follow Local Policy and ProcedureFollow Local Policy and Procedure Comprehensive run report must be Comprehensive run report must be

completed for each patient when completed for each patient when time permitstime permits

Refusal of CareRefusal of Care

Potential for LiabilityPotential for Liability Good DocumentationGood Documentation Make it clearMake it clear

Refusal of CareRefusal of Care

The litigation rate for EMS has been steadily increasing

1048657 According to one study patients evaluatedby paramedics but not transported to thehospital account for 50 to 90 of EMSlawsuitsrdquo

1048657 Documentation is your best defenserdquo

DocumentationDocumentation

Physical FindingsPhysical Findings The advice you give the patient about The advice you give the patient about

being transported and the associated being transported and the associated risks for not being transportedrisks for not being transported

Clinical indications that patient is Clinical indications that patient is competent to make a rational decisioncompetent to make a rational decision

Signatures of the patient and witnessSignatures of the patient and witness Full narrativeFull narrative Advise to call 911 if condition changesAdvise to call 911 if condition changes

Do not at any time attempt to talk the patient out of going to the hospital

If you feel strongly that the patient should be seen make every attempt to convince them they should be seen

Donrsquot say lsquo I agree you donrsquot need to gordquo even if you agree

What not to sayWhat not to say

A patient suffers a diabetic emergency She is treated by the local EMS crew with an A patient suffers a diabetic emergency She is treated by the local EMS crew with an IV an ampule of D50 and transported to the closet hospital despite family members IV an ampule of D50 and transported to the closet hospital despite family members telling you that the patient does not go theretelling you that the patient does not go there

Transport is uneventful and care is turned over to the ED Nurse with a quick verbal Transport is uneventful and care is turned over to the ED Nurse with a quick verbal reportreport

An hour later a private ambulance is called to transport the patient to her desired An hour later a private ambulance is called to transport the patient to her desired hospital for definitive care They notice the IV has infiltrated and D50 got into her hospital for definitive care They notice the IV has infiltrated and D50 got into her surrounding tissuessurrounding tissues

The patient suffers significant tissue damage which requires a fasciotomy to The patient suffers significant tissue damage which requires a fasciotomy to decompress her hand and forearm She has permanent nerve damage and requires decompress her hand and forearm She has permanent nerve damage and requires skin graftingskin grafting

Initial Transport Agency-CFDInitial Transport Agency-CFD

First Receiving Hospital-St Anthony HospitalFirst Receiving Hospital-St Anthony Hospital

Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998

Lets Finish upLets Finish up

Be ProfessionalBe Professional AccurateAccurate ConsistentConsistent ThroughThrough ClearClear BriefBrief Paint the PicturePaint the Picture CollaborativeCollaborative

Legible spelling Legible spelling correctcorrect

Tell the TruthTell the Truth Donrsquot duplicate infoDonrsquot duplicate info Follow ProtocolsFollow Protocols Plain LanguagePlain Language Relevant InformationRelevant Information ldquoldquoThe JURYrdquoThe JURYrdquo Have your partner Have your partner

reviewreview

Special ConsiderationsSpecial Considerations

Exposure and InjuryExposure and Injury Mass CasualtyMass Casualty Interfacility TransportsInterfacility Transports RefusalsRefusals

Mass Casualty EventsMass Casualty Events

Documentation may have to be Documentation may have to be postponedpostponed

Follow Local Policy and ProcedureFollow Local Policy and Procedure Comprehensive run report must be Comprehensive run report must be

completed for each patient when completed for each patient when time permitstime permits

Refusal of CareRefusal of Care

Potential for LiabilityPotential for Liability Good DocumentationGood Documentation Make it clearMake it clear

Refusal of CareRefusal of Care

The litigation rate for EMS has been steadily increasing

1048657 According to one study patients evaluatedby paramedics but not transported to thehospital account for 50 to 90 of EMSlawsuitsrdquo

1048657 Documentation is your best defenserdquo

DocumentationDocumentation

Physical FindingsPhysical Findings The advice you give the patient about The advice you give the patient about

being transported and the associated being transported and the associated risks for not being transportedrisks for not being transported

Clinical indications that patient is Clinical indications that patient is competent to make a rational decisioncompetent to make a rational decision

Signatures of the patient and witnessSignatures of the patient and witness Full narrativeFull narrative Advise to call 911 if condition changesAdvise to call 911 if condition changes

Do not at any time attempt to talk the patient out of going to the hospital

If you feel strongly that the patient should be seen make every attempt to convince them they should be seen

Donrsquot say lsquo I agree you donrsquot need to gordquo even if you agree

What not to sayWhat not to say

A patient suffers a diabetic emergency She is treated by the local EMS crew with an A patient suffers a diabetic emergency She is treated by the local EMS crew with an IV an ampule of D50 and transported to the closet hospital despite family members IV an ampule of D50 and transported to the closet hospital despite family members telling you that the patient does not go theretelling you that the patient does not go there

Transport is uneventful and care is turned over to the ED Nurse with a quick verbal Transport is uneventful and care is turned over to the ED Nurse with a quick verbal reportreport

An hour later a private ambulance is called to transport the patient to her desired An hour later a private ambulance is called to transport the patient to her desired hospital for definitive care They notice the IV has infiltrated and D50 got into her hospital for definitive care They notice the IV has infiltrated and D50 got into her surrounding tissuessurrounding tissues

The patient suffers significant tissue damage which requires a fasciotomy to The patient suffers significant tissue damage which requires a fasciotomy to decompress her hand and forearm She has permanent nerve damage and requires decompress her hand and forearm She has permanent nerve damage and requires skin graftingskin grafting

Initial Transport Agency-CFDInitial Transport Agency-CFD

First Receiving Hospital-St Anthony HospitalFirst Receiving Hospital-St Anthony Hospital

Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998

Lets Finish upLets Finish up

Be ProfessionalBe Professional AccurateAccurate ConsistentConsistent ThroughThrough ClearClear BriefBrief Paint the PicturePaint the Picture CollaborativeCollaborative

Legible spelling Legible spelling correctcorrect

Tell the TruthTell the Truth Donrsquot duplicate infoDonrsquot duplicate info Follow ProtocolsFollow Protocols Plain LanguagePlain Language Relevant InformationRelevant Information ldquoldquoThe JURYrdquoThe JURYrdquo Have your partner Have your partner

reviewreview

Mass Casualty EventsMass Casualty Events

Documentation may have to be Documentation may have to be postponedpostponed

Follow Local Policy and ProcedureFollow Local Policy and Procedure Comprehensive run report must be Comprehensive run report must be

completed for each patient when completed for each patient when time permitstime permits

Refusal of CareRefusal of Care

Potential for LiabilityPotential for Liability Good DocumentationGood Documentation Make it clearMake it clear

Refusal of CareRefusal of Care

The litigation rate for EMS has been steadily increasing

1048657 According to one study patients evaluatedby paramedics but not transported to thehospital account for 50 to 90 of EMSlawsuitsrdquo

1048657 Documentation is your best defenserdquo

DocumentationDocumentation

Physical FindingsPhysical Findings The advice you give the patient about The advice you give the patient about

being transported and the associated being transported and the associated risks for not being transportedrisks for not being transported

Clinical indications that patient is Clinical indications that patient is competent to make a rational decisioncompetent to make a rational decision

Signatures of the patient and witnessSignatures of the patient and witness Full narrativeFull narrative Advise to call 911 if condition changesAdvise to call 911 if condition changes

Do not at any time attempt to talk the patient out of going to the hospital

If you feel strongly that the patient should be seen make every attempt to convince them they should be seen

Donrsquot say lsquo I agree you donrsquot need to gordquo even if you agree

What not to sayWhat not to say

A patient suffers a diabetic emergency She is treated by the local EMS crew with an A patient suffers a diabetic emergency She is treated by the local EMS crew with an IV an ampule of D50 and transported to the closet hospital despite family members IV an ampule of D50 and transported to the closet hospital despite family members telling you that the patient does not go theretelling you that the patient does not go there

Transport is uneventful and care is turned over to the ED Nurse with a quick verbal Transport is uneventful and care is turned over to the ED Nurse with a quick verbal reportreport

An hour later a private ambulance is called to transport the patient to her desired An hour later a private ambulance is called to transport the patient to her desired hospital for definitive care They notice the IV has infiltrated and D50 got into her hospital for definitive care They notice the IV has infiltrated and D50 got into her surrounding tissuessurrounding tissues

The patient suffers significant tissue damage which requires a fasciotomy to The patient suffers significant tissue damage which requires a fasciotomy to decompress her hand and forearm She has permanent nerve damage and requires decompress her hand and forearm She has permanent nerve damage and requires skin graftingskin grafting

Initial Transport Agency-CFDInitial Transport Agency-CFD

First Receiving Hospital-St Anthony HospitalFirst Receiving Hospital-St Anthony Hospital

Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998

Lets Finish upLets Finish up

Be ProfessionalBe Professional AccurateAccurate ConsistentConsistent ThroughThrough ClearClear BriefBrief Paint the PicturePaint the Picture CollaborativeCollaborative

Legible spelling Legible spelling correctcorrect

Tell the TruthTell the Truth Donrsquot duplicate infoDonrsquot duplicate info Follow ProtocolsFollow Protocols Plain LanguagePlain Language Relevant InformationRelevant Information ldquoldquoThe JURYrdquoThe JURYrdquo Have your partner Have your partner

reviewreview

Refusal of CareRefusal of Care

Potential for LiabilityPotential for Liability Good DocumentationGood Documentation Make it clearMake it clear

Refusal of CareRefusal of Care

The litigation rate for EMS has been steadily increasing

1048657 According to one study patients evaluatedby paramedics but not transported to thehospital account for 50 to 90 of EMSlawsuitsrdquo

1048657 Documentation is your best defenserdquo

DocumentationDocumentation

Physical FindingsPhysical Findings The advice you give the patient about The advice you give the patient about

being transported and the associated being transported and the associated risks for not being transportedrisks for not being transported

Clinical indications that patient is Clinical indications that patient is competent to make a rational decisioncompetent to make a rational decision

Signatures of the patient and witnessSignatures of the patient and witness Full narrativeFull narrative Advise to call 911 if condition changesAdvise to call 911 if condition changes

Do not at any time attempt to talk the patient out of going to the hospital

If you feel strongly that the patient should be seen make every attempt to convince them they should be seen

Donrsquot say lsquo I agree you donrsquot need to gordquo even if you agree

What not to sayWhat not to say

A patient suffers a diabetic emergency She is treated by the local EMS crew with an A patient suffers a diabetic emergency She is treated by the local EMS crew with an IV an ampule of D50 and transported to the closet hospital despite family members IV an ampule of D50 and transported to the closet hospital despite family members telling you that the patient does not go theretelling you that the patient does not go there

Transport is uneventful and care is turned over to the ED Nurse with a quick verbal Transport is uneventful and care is turned over to the ED Nurse with a quick verbal reportreport

An hour later a private ambulance is called to transport the patient to her desired An hour later a private ambulance is called to transport the patient to her desired hospital for definitive care They notice the IV has infiltrated and D50 got into her hospital for definitive care They notice the IV has infiltrated and D50 got into her surrounding tissuessurrounding tissues

The patient suffers significant tissue damage which requires a fasciotomy to The patient suffers significant tissue damage which requires a fasciotomy to decompress her hand and forearm She has permanent nerve damage and requires decompress her hand and forearm She has permanent nerve damage and requires skin graftingskin grafting

Initial Transport Agency-CFDInitial Transport Agency-CFD

First Receiving Hospital-St Anthony HospitalFirst Receiving Hospital-St Anthony Hospital

Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998

Lets Finish upLets Finish up

Be ProfessionalBe Professional AccurateAccurate ConsistentConsistent ThroughThrough ClearClear BriefBrief Paint the PicturePaint the Picture CollaborativeCollaborative

Legible spelling Legible spelling correctcorrect

Tell the TruthTell the Truth Donrsquot duplicate infoDonrsquot duplicate info Follow ProtocolsFollow Protocols Plain LanguagePlain Language Relevant InformationRelevant Information ldquoldquoThe JURYrdquoThe JURYrdquo Have your partner Have your partner

reviewreview

Refusal of CareRefusal of Care

The litigation rate for EMS has been steadily increasing

1048657 According to one study patients evaluatedby paramedics but not transported to thehospital account for 50 to 90 of EMSlawsuitsrdquo

1048657 Documentation is your best defenserdquo

DocumentationDocumentation

Physical FindingsPhysical Findings The advice you give the patient about The advice you give the patient about

being transported and the associated being transported and the associated risks for not being transportedrisks for not being transported

Clinical indications that patient is Clinical indications that patient is competent to make a rational decisioncompetent to make a rational decision

Signatures of the patient and witnessSignatures of the patient and witness Full narrativeFull narrative Advise to call 911 if condition changesAdvise to call 911 if condition changes

Do not at any time attempt to talk the patient out of going to the hospital

If you feel strongly that the patient should be seen make every attempt to convince them they should be seen

Donrsquot say lsquo I agree you donrsquot need to gordquo even if you agree

What not to sayWhat not to say

A patient suffers a diabetic emergency She is treated by the local EMS crew with an A patient suffers a diabetic emergency She is treated by the local EMS crew with an IV an ampule of D50 and transported to the closet hospital despite family members IV an ampule of D50 and transported to the closet hospital despite family members telling you that the patient does not go theretelling you that the patient does not go there

Transport is uneventful and care is turned over to the ED Nurse with a quick verbal Transport is uneventful and care is turned over to the ED Nurse with a quick verbal reportreport

An hour later a private ambulance is called to transport the patient to her desired An hour later a private ambulance is called to transport the patient to her desired hospital for definitive care They notice the IV has infiltrated and D50 got into her hospital for definitive care They notice the IV has infiltrated and D50 got into her surrounding tissuessurrounding tissues

The patient suffers significant tissue damage which requires a fasciotomy to The patient suffers significant tissue damage which requires a fasciotomy to decompress her hand and forearm She has permanent nerve damage and requires decompress her hand and forearm She has permanent nerve damage and requires skin graftingskin grafting

Initial Transport Agency-CFDInitial Transport Agency-CFD

First Receiving Hospital-St Anthony HospitalFirst Receiving Hospital-St Anthony Hospital

Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998

Lets Finish upLets Finish up

Be ProfessionalBe Professional AccurateAccurate ConsistentConsistent ThroughThrough ClearClear BriefBrief Paint the PicturePaint the Picture CollaborativeCollaborative

Legible spelling Legible spelling correctcorrect

Tell the TruthTell the Truth Donrsquot duplicate infoDonrsquot duplicate info Follow ProtocolsFollow Protocols Plain LanguagePlain Language Relevant InformationRelevant Information ldquoldquoThe JURYrdquoThe JURYrdquo Have your partner Have your partner

reviewreview

DocumentationDocumentation

Physical FindingsPhysical Findings The advice you give the patient about The advice you give the patient about

being transported and the associated being transported and the associated risks for not being transportedrisks for not being transported

Clinical indications that patient is Clinical indications that patient is competent to make a rational decisioncompetent to make a rational decision

Signatures of the patient and witnessSignatures of the patient and witness Full narrativeFull narrative Advise to call 911 if condition changesAdvise to call 911 if condition changes

Do not at any time attempt to talk the patient out of going to the hospital

If you feel strongly that the patient should be seen make every attempt to convince them they should be seen

Donrsquot say lsquo I agree you donrsquot need to gordquo even if you agree

What not to sayWhat not to say

A patient suffers a diabetic emergency She is treated by the local EMS crew with an A patient suffers a diabetic emergency She is treated by the local EMS crew with an IV an ampule of D50 and transported to the closet hospital despite family members IV an ampule of D50 and transported to the closet hospital despite family members telling you that the patient does not go theretelling you that the patient does not go there

Transport is uneventful and care is turned over to the ED Nurse with a quick verbal Transport is uneventful and care is turned over to the ED Nurse with a quick verbal reportreport

An hour later a private ambulance is called to transport the patient to her desired An hour later a private ambulance is called to transport the patient to her desired hospital for definitive care They notice the IV has infiltrated and D50 got into her hospital for definitive care They notice the IV has infiltrated and D50 got into her surrounding tissuessurrounding tissues

The patient suffers significant tissue damage which requires a fasciotomy to The patient suffers significant tissue damage which requires a fasciotomy to decompress her hand and forearm She has permanent nerve damage and requires decompress her hand and forearm She has permanent nerve damage and requires skin graftingskin grafting

Initial Transport Agency-CFDInitial Transport Agency-CFD

First Receiving Hospital-St Anthony HospitalFirst Receiving Hospital-St Anthony Hospital

Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998

Lets Finish upLets Finish up

Be ProfessionalBe Professional AccurateAccurate ConsistentConsistent ThroughThrough ClearClear BriefBrief Paint the PicturePaint the Picture CollaborativeCollaborative

Legible spelling Legible spelling correctcorrect

Tell the TruthTell the Truth Donrsquot duplicate infoDonrsquot duplicate info Follow ProtocolsFollow Protocols Plain LanguagePlain Language Relevant InformationRelevant Information ldquoldquoThe JURYrdquoThe JURYrdquo Have your partner Have your partner

reviewreview

Do not at any time attempt to talk the patient out of going to the hospital

If you feel strongly that the patient should be seen make every attempt to convince them they should be seen

Donrsquot say lsquo I agree you donrsquot need to gordquo even if you agree

What not to sayWhat not to say

A patient suffers a diabetic emergency She is treated by the local EMS crew with an A patient suffers a diabetic emergency She is treated by the local EMS crew with an IV an ampule of D50 and transported to the closet hospital despite family members IV an ampule of D50 and transported to the closet hospital despite family members telling you that the patient does not go theretelling you that the patient does not go there

Transport is uneventful and care is turned over to the ED Nurse with a quick verbal Transport is uneventful and care is turned over to the ED Nurse with a quick verbal reportreport

An hour later a private ambulance is called to transport the patient to her desired An hour later a private ambulance is called to transport the patient to her desired hospital for definitive care They notice the IV has infiltrated and D50 got into her hospital for definitive care They notice the IV has infiltrated and D50 got into her surrounding tissuessurrounding tissues

The patient suffers significant tissue damage which requires a fasciotomy to The patient suffers significant tissue damage which requires a fasciotomy to decompress her hand and forearm She has permanent nerve damage and requires decompress her hand and forearm She has permanent nerve damage and requires skin graftingskin grafting

Initial Transport Agency-CFDInitial Transport Agency-CFD

First Receiving Hospital-St Anthony HospitalFirst Receiving Hospital-St Anthony Hospital

Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998

Lets Finish upLets Finish up

Be ProfessionalBe Professional AccurateAccurate ConsistentConsistent ThroughThrough ClearClear BriefBrief Paint the PicturePaint the Picture CollaborativeCollaborative

Legible spelling Legible spelling correctcorrect

Tell the TruthTell the Truth Donrsquot duplicate infoDonrsquot duplicate info Follow ProtocolsFollow Protocols Plain LanguagePlain Language Relevant InformationRelevant Information ldquoldquoThe JURYrdquoThe JURYrdquo Have your partner Have your partner

reviewreview

A patient suffers a diabetic emergency She is treated by the local EMS crew with an A patient suffers a diabetic emergency She is treated by the local EMS crew with an IV an ampule of D50 and transported to the closet hospital despite family members IV an ampule of D50 and transported to the closet hospital despite family members telling you that the patient does not go theretelling you that the patient does not go there

Transport is uneventful and care is turned over to the ED Nurse with a quick verbal Transport is uneventful and care is turned over to the ED Nurse with a quick verbal reportreport

An hour later a private ambulance is called to transport the patient to her desired An hour later a private ambulance is called to transport the patient to her desired hospital for definitive care They notice the IV has infiltrated and D50 got into her hospital for definitive care They notice the IV has infiltrated and D50 got into her surrounding tissuessurrounding tissues

The patient suffers significant tissue damage which requires a fasciotomy to The patient suffers significant tissue damage which requires a fasciotomy to decompress her hand and forearm She has permanent nerve damage and requires decompress her hand and forearm She has permanent nerve damage and requires skin graftingskin grafting

Initial Transport Agency-CFDInitial Transport Agency-CFD

First Receiving Hospital-St Anthony HospitalFirst Receiving Hospital-St Anthony Hospital

Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998Wojcik v City of Chicago 702 NE 2d 303 - Ill Appellate Court 1st Dist 2nd Div 1998

Lets Finish upLets Finish up

Be ProfessionalBe Professional AccurateAccurate ConsistentConsistent ThroughThrough ClearClear BriefBrief Paint the PicturePaint the Picture CollaborativeCollaborative

Legible spelling Legible spelling correctcorrect

Tell the TruthTell the Truth Donrsquot duplicate infoDonrsquot duplicate info Follow ProtocolsFollow Protocols Plain LanguagePlain Language Relevant InformationRelevant Information ldquoldquoThe JURYrdquoThe JURYrdquo Have your partner Have your partner

reviewreview

Lets Finish upLets Finish up

Be ProfessionalBe Professional AccurateAccurate ConsistentConsistent ThroughThrough ClearClear BriefBrief Paint the PicturePaint the Picture CollaborativeCollaborative

Legible spelling Legible spelling correctcorrect

Tell the TruthTell the Truth Donrsquot duplicate infoDonrsquot duplicate info Follow ProtocolsFollow Protocols Plain LanguagePlain Language Relevant InformationRelevant Information ldquoldquoThe JURYrdquoThe JURYrdquo Have your partner Have your partner

reviewreview