documentation: professionalism, integrity & funding amy gutman md ems medical director...
TRANSCRIPT
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Documentation:Professionalism, INTEGRITY &
funding
Amy Gutman MDEMS Medical Director
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Who Cares About Documentation?
• CYA!
• Data drives research; research drives outcomes
• CQI & research show you how good your department is, & highlight room for improvement
• You are professionals – your documentation should reflect this professionalism
• Not to be bitchy…but poor care (or the perception of poor care) reflects badly on me. You work under my license & at my discretion. Don’t piss me off.
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But one Chart Doesn’t Change Patient Care, Does It?
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What Did Data Do For SFD?
• Drove change to ETCO2-driven appropriate ventilation vs “hypo” or “hyper” ventilation
• Proved that EMTs & EMT-Ps apply high level technical & physiological information to improve cardiac arrest outcomes
• Improved ROSC from 22% to 38% & survival from 4% to 11% from ALLALL cardiac arrests in one year
• Changes in Policy:– Cardiac Arrest– Vehicle & Equipment Sanitation– No Hauls– Death-In-Field– Skills Tracking– Personnel Distribution
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What Can Data Do For your fd?
• Justify personnel
• Defend increased number of response vehicles & transport units
• Show responsibility to the patient, as well as overall improved quality of care
• Move towards greatness – Identity strengths & weaknesses– Document and publish successes
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Notebooks
• Every PCR generates 30-50 data points
• Every arrest provides an additional 16 data points
• Missing data weakens patient care, CQI, billing & research
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Charting Methods
• It does not matter which methods you use, as long as the documentation is thorough, complete & professional
• Yes…spelling & punctuation count
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DCHARTE & Soap
D Dispatch Time / Type
C CC
H History
A Assessment
R Rx at Scene
T Treatment Enroute
E Exemptions
S Subjective
O Observations
A Assessment
P Plan
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SAMPLE – OPQRST
O Onset
P Provokes
Q Quality
R Radiation
S Severity (1-10 scale)
T Time
S SSX
A Allergies
M Meds
P PMH
L Last PO intake
E Events (i.e. MOI)
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General ConceptsAKA “Don’t Overload the Truck”
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Key areas of emt liability
• Bad Refusals– Failure to consider
“competency”
– Failure to document
• Negligence– Ordinary negligence vs.
Gross negligence
• Abandonment– Transfer of care
– Failure to document
• Patient Care Issues– Airway
– Spinal Immobilization
– Equipment Failure
– NV status
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NEGLIGENCE elements
• Duty:– “Obligatory conduct owed by a person to another person.” – In tort law, duty is a legally sanctioned obligation, the breach of which results in
liability
• Breach: – “Failure to perform a duty owed to another; a failure to exercise that care which
a reasonable, prudent man would exercise under similar circumstances.”
• Damages: – “For actual harm resulting from the defendant’s wrongful act or omission”
• Proximate Cause:– “Results were caused by one’s conduct or omission.”
Barron’s Law Dictionary, Fifth Edition, 2003
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Keep accurate times
•Dispatched to Scene
•Arrival On Scene •BLS & ALS
•Actions On Scene•i.e. Medications•i.e. Time to shock
•Time on Scene
•Departure to Hospital
•Arrival to Hospital
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Abbreviations
• No home-grown abbreviations– DRT– DFU– BFN– LOL
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SPELLING COUNTS
• If a jury looks at a chart full of basic errors, they will conclude that you are as sloppy at patient care as you are at documentation
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Bystanders & transfers
• Include name, level of training, license number(s) of ANY medical personnel who have assisted at any point during assessment or patient care
• Include initials or badge number person writing the narrative
• When transferring care, document name/ position who accepts patient
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This Is Not CSI
• Unless you’re a medical or forensic specialist don’t make assumptions– i.e. Entrance & exit wounds
• Explain what was found & how it appeared– “Infant was found face-down under her bed-sheets,
cold, mottled, cyanotic, with vomitus noted in oropharynx”
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Charting
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Chief Complaint
• Why did patient call 911?
• Pt’s words in quotes
• “Upon arrival found 54 yo F on couch. Pt reports “feeling like someone is sitting on my chest.”
» vs
• “Called to house for possible heart attack”
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HPI
• Descriptive narrative telling a story from onset of symptoms, bystander involvement, prehospital
treatments to time of transfer
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History Obtained from someone other than patient
• Indicate why– Language barrier– Disability
• Document who provided history– Translator– Family– Friend
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PMH/ PSH
• Past Medical & Surgical– Medical / surgical– Similar presentations: “The last time my chest hurt this
much, I went to the cath lab”
• Allergies– Drug & reaction
• Medications– Write “BP med” if that is what pt states– Be as thorough as possible
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Good emts aren’t Helped By bad Documentation
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SAD BUT TRUE EXAMPLES
• “Arrived on scene, pt sick to her stomack, said she ate some food that may be bad. V/S normal. Placed pt in POC and transported to ER.”
• “On scene found patient drunk. He’s a regular who always gets drunk. He called for EMS to avoid going to jail. He stinks bad. We turned him over to PO.”
• “Caled 4 medcal raisins. Patience in floore. She wus sikk. She puuked on floore. Blud wus in the puok. She didn’t waunt us so we lift.”
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Vitals are vital
• Complete Vitals:– BP– RR (effort / number)
– O2 sat / capnography
– HR– Temperature
• Repeat serially
• Note changes in pt status– If you do something…what
happened?
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Dispatch
• Computer Aided Dispatch– Best Friend vs Worst Enemy– Only as good as the dispatchers
& dispatch tools
• Nature & Type of call
• Updates Enroute – CPR in progress
– Police on scene
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MVC HPI
HPI should emphasize mechanism of injury
What Is missing from above HPI?
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MVC HPI
• Types of vehicles involved
• Principal Direction of Force (PDOF)
• Speed of both vehicles
• Description of Damage/ Intrusion
• Number of Patients
• Position of Patients
• Death/ Serious Injury in Passenger
• Restraints
• Ambulatory at Scene
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Trauma HPI
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Assessment
• Your “impression” rather than a diagnosis
• Observations & subjective information
• “51 yo M with CP & ST elevations in II, III, AvF”
• “Provider Impression” – Essential for billing– Proof that pt had an ALS
assessment & treatment
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Treatment
• All interventions
• Includes:– Bystander interventions
prior to your arrival– Your interventions– Any positive or negative
response to treatment• “Pt placed on 100%
NRB. Sat increased from 88 to 97%, RR decreased from 34 to 18/min”
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Examples of “Treatments/ Interventions”
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Other Treatments & Interventions
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Transportation & triage
• Methods of transfer to unit & to hospital- Seated
- Supine
- C spine immobilization
• Any treatment initiated or continued while en-route– “VS reassessed q 15mins
– O2 at 10 LPM NRB due to decreased O2 sat from 99% RA to 90% RA”
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Transportation & triage
• Document name & title of the person to which patient care was transferred
• Reason for Triage:– Closest facility– Trauma Triage– Patient request– If “Requesting” & “Transport” hospitals are different,
document why
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Exceptions TO STANDARD OF CARE
• All treatments must be consistent with OEMS protocols
• Document everything that was done– If a standard treatment was not done,
why not? – Any “exception” from norm, i.e. “Patient
refused ASA due to known allergy”
• CYA - Justifies why you did or did not do something
• Keeps CQI & Medical Director off your back
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Trauma Patients
• Trauma triage legislation requires providers to document if pt met criteria for transportation to a trauma center
• Try to justify using at least 2 criteria:– “Pt unconscious following
front-impact MVC. Transported to a Level 1 trauma center due to bilateral femur fractures.”
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Refusals
• NEVER from pediatrics, or intoxicated/ confused adults
• Thoroughly document effort to provide informed consent including potential complications (use & write the word “death”)
• All refusals must be signed, including signatures by the patient/ guardian/ power of attorney, provider & witness– If police or family not available, your partner’s signature is adequate
• Refusals are the most common prehospital documents to show up in court – pay extra attention to spelling, grammar, punctuation, signatures, times & dates
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DNRs / MOLST
• Patient can change mind at any time– “Patient requested EMS to disregard DNR”
• Include statement regarding DNR in PCR– Date document signed & who signed it
• If the paperwork is not physically present it does not exist
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Cardiac arrest documentation
• Reportable to state & national registries
• Affects policy, national standards & patient outcomes
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Utstein CA Data CollectionUtstein CA Data Collection
• Date / Time
• Incident Number
• Accepting Hospital
• Age / DOB
• Gender / Race
• Past Medical History
• Down Time
• Time to Patient Contact
• Time On Scene
• Witnessed Arrest
• Bystander CPR
• Initial & Serial Rhythms
• Initial & Serial Vitals
• Ventilation rate
• Initial & Serial ETCO2
• Any Interventions (meds, defibrillation)
• ROSC
• HPI Narrative
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BASICSXXXXX
xx
xx
John Smith
111-11-1111
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Good Narratives tell
“Stories”
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•Should have “4 Point” intubation confirmation in narrative
•ETT visualized passing through cords
•ETCO2 confirmation
•BL breath sounds ausculated
•No epigastric sounds
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Sloppy & Incomplete
This patient SURVIVED a cardiac arrest…wouldn’t it have been nice to know why?
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Time to Patient ContactTime to Patient Contact
•NOT time “on scene”
•If BLS unit arrived first, document their interventions
•Time on scene also important to document; national standards are <10 mins
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Witnessed Arrest & Bystander CPRWitnessed Arrest & Bystander CPR
• “Yes” or “No”
• Was AED was used on scene?
• Important for tracking community involvement & outcomes
• May help in receiving public health grants for education
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Vitals are VITAL!
• If patient has no vitals or spontaneous respirations, document: – Rate at which you are ventilating patient– ETCO2
– Rate you are performing chest compressions
• New CPR Guidelines & ongoing research into the “best” resuscitation strategies
• ETCO2 is not just a number, it may be a predictor of outcome
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Rhythm
• Initial
• Changes with any intervention
• Final rhythm at presentation to ED
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FYI
• NV status before & after splinting & spinal immobilization
• Loose/ missing teeth prior to intubation
• Subjective “feelings” are assessments
• Protect patient confidentiality
• Falsification of EMS reports equals fraud
• Spelling, grammar & punctuation count – this is a legal document and reflects your professionalism
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PUNCTUATION IS POWERFUL!
• An English professor wrote these words on a chalkboard and asked his students to punctuate it correctly:
• “A woman without her man is nothing”
• All of the males in the class wrote:• “A woman, without her man, is nothing”
• All of the females in the class wrote:• “A woman: without her, man is nothing”
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