documentationdocumentation emt 170 emergency communications and patient transportation (cars &...
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DocumentationDocumentationDocumentationDocumentation
EMT 170 EMT 170 Emergency Communications and Emergency Communications and
Patient TransportationPatient Transportation(Cars & Radios)(Cars & Radios)
Documentation – Purpose
• Provides a record of scene information that may not be available from any other source
• Provides information for the continuity of patient care from one healthcare provider to another
• Provides a record of specific pre-hospital interventions performed or attempted
• Provides medical legal evidence• Reveals any significant changes in the
patient’s condition• Provides an internal tool for statistics,
budgeting, QA and education
Patient Care Report – Types of Reports
• Traditional written report– Typically provides check boxes and a
narrative section– EMT completes it in written form
• Computer-based report– Generated on an electronic clipboard or
mobile data terminal– EMT enters information by special
instrument or keyboard
Written Patient Care Report(PCR)
Written Patient Care Report(PCR)
Computer Based Report System
PCR-Report Elements• Run data
• Patient data
• Narrative information
Run Data• Service name • Unit number• Crew license numbers and/or
names• Location of call• Response times mileage
Patient Data• Patient’s name
• Age
• Location of
patient
• Pupillary
response
• Assessment
• Address
• Sex
• LOC
• Vital signs
• Care provided
• DOB
• MOI/NOI
• Sensation
• PMH
• Response to
treatment
Narrative• Used to document
– Patient complaint/history– Observation– Physical assessment finding– Care delivered by EMS crew– Changes in patient condition
•SOAPSOAP
General Guidelines
• Collect all patient information• Complete all blanks and check all
pertinent boxes on call report form• Do not leave any spaces blank,
mark “N/A” if item does not apply• Begin narrative by documenting
the patient's LOC
General Guidelines (cont.)
• Attach EKG documentation (where applicable) with date, time and patient's name on it
• Sign the report• Leave a copy of the report with
the patient’s chart
Items to Document
• Patient’s chief complaint using patient’s own words within quotation marks if possible
• History of present illness or injury using OPQRST format
• Physical assessment findings including pertinent positives and pertinent negatives
• Significant pertinent past medical history including surgeries, hospitalizations, illnesses or injuries
Items to Document (cont.)
• Allergies and current medications• Interventions, who performed
them, time performed, and the patient’s response or lack of response to interventions
• Vital signs and times obtained
Writing a Narrative
• Use plain language and medical terminology
• Avoid slang
• Use only recognized abbreviations
• Spelling general neatness are imperative to convey professionalism
SOAP MethodS – subjective
– Information the patient tells you– Patient symptoms
O – objective– Information the EMT observes about the scene and
possible injuries
A – assessment– EMTs evaluation of the situation, the patient’s chief
complaint and findings based on the exam
P – plan– The plan of action and care delivered the EMT
Other Narrative Forms
• Head-to-toe format
• Chronological format
Correcting Mistakes
• Do not erase or mark out a mistake– Draw a single line through the error
and place initials beside the line– Add the correct information following
the correction– If information was initially omitted,
add a note with additional information, the date, and the EMTs initials
Errors
• DO NOT attempt to cover mistake
• Document what did or did not happen and what corrective action (if any) was taken
• Falsifying information on a PCR is harmful to the patient and may lead to the suspension or revocation of the EMTs certification and other legal action
Summary• Documentation is the most important non-
clinical skill possessed by the EMT• The patient care report must be accurate and
report both subjective and objective findings, physical assessment results, care and treatment rendered and any significant observation of the scene
• The PCR is considered a legal document that serves as an official record of care given
• The PCR is the EMTs first line of defense if questions are later raised about the incident