PEC11 Chap 04 - Documentation.pdf

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Prehospital: Emergency Care

Eleventh Edition

Chapter 4

Documentation

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Learning Readiness

• EMS Education Standards, text p. 64.

• Chapter Objectives, text p. 64.

• Key Terms, text p. 64.

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Setting the Stage

• Overview of Lesson Topics

– Functions of the prehospital care report

– Collection of data in PCRs

– Medical abbreviations

– Legal concerns

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Case Study Introduction

(1 of 2)

EMT Rory Bruns picked up the phone in the Station 4 crew room on the second ring. “EMT Bruns. How can I help

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Case Study Introduction

(2 of 2)

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Case Study

(1 of 4)

• How can the PCR help Rory?

• What kind of information will the parties involved in the legal case be looking for in the PCR?

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Introduction

• Documentation of information about EMS calls serve several purposes.

• The record of care provided is called a patient care report (PCR).

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Functions of the P

C

R

(1 of 3)

1. Continuity of medical care

– Emergency department (ED) personnel will reference the PCR.

2. Administrative uses

– Billing and insurance reimbursement

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Functions of the P

C

R

(2 of 3)

3. Legal document

– The patient may be a crime victim.

– Protection in the event of a civil lawsuit.

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Functions of the P

C

R

(3 of 3)

4. Education and research

– PCRs can be a rich source of data to allow research on many issues.

5. Continuous Quality Improvement

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Collection of Data in P

C

Rs

(1 of 13)

• All documentation must be careful and thorough.

• There are paper and electronic PCRs.

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Figure 4-3 (c) A Toughpad with Human

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Collection of Data in P

C

R

s

(2 of 13)

• Two basic rules of PCRs

1. If it wasn't written

down, it wasn't done.

2. If it wasn't done, don't write it down.

Figure 4-4 A smart phone may have an app for direct data entry that is then transferred to a

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Collection of Data in P

C

R

s

(3 of 13)

• US DOT Minimum data set

– Established by the U.S. Department of Transportation (DOT)

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Collection of Data in P

C

R

s

(4 of 13)

1. Patient Information of Minimum Data Set

– Chief complaint

– Level of responsiveness

– Blood pressure

– Skin perfusion

– Skin color, temperature, condition

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Collection of Data in P

C

R

s

(5 of 13)

2. Administrative Information of Minimum Data Set

– Time incident was reported

– Time EMS unit was notified

– Time of arrival at patient

– Time unit left the scene

– Time unit arrived at destination

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Collection of Data in P

C

R

s

(6 of 13)

• PCRs usually have these sections:

– Administrative information

– Patient demographic and other data

– Vital signs

– Patient narrative

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Collection of Data in P

C

R

s

(7 of 13)

• Other Sections of PCR

1. Administrative information (or run data)

▪ EMS unit number and run or call number

▪ Names certification levels of crew

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Collection of Data in P

C

R

s

(8 of 13)

2. Patient demographic and other data

▪ Patient’s name, age, sex, race, birth date

▪ Patient’s home address

▪ Insurance and billing information

▪ Location patient was found

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Collection of Data in P

C

R

s

(9 of 13)

3. Vital signs

▪ At least two sets of vital signs are needed.

▪ Record the patient's position when vitals were obtained.

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Collection of Data in P

C

R

s

(10 of 13)

4. Patient narrative

▪ Information from the physical exam and pertinent scene information

▪ Includes the chief complaint, patient’s history, and physical exam findings.

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Collection of Data in P

C

R

s

(11 of 13)

4. Patient narrative

▪ Objective information is verifiable or measurable.

▪ Subjective information is based on perceptions or opinions.

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Collection of Data in P

C

R

s

(12 of 13)

5. Treatment

▪ Detail treatment in chronological order.

▪ Document the time of each treatment.

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Collection of Data in P

C

R

s

(13 of 13)

• Use of accurate and synchronized clocks

– Dispatch, vehicle, and EMT timekeeping devices must all agree with one another.

– Needed for accurate documentation of medical care.

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Match the Descriptions on the Left with the Type of

P

C

R Information Listed on the Right. Click in Each

Box on the Left to Check Your Answers

1. Fill in the blank pulse rate

2. Fill in the blank EMTs’ names

3. Fill in the blank “Pt. c/o

headache on right side of head for 3 hours.”

4. Fill in the blank 4 LPMO by NC

a. Administrative information

b. Patient demographics

c. Vital signs

d. Narrative

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Case Study

(2 of 4)

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Case Study

(3 of 4)

The county attorney is looking for evidence that might

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Case Study

(4 of 4)

• What specific elements of the narrative could be important in the prosecution’s case?

• What weaknesses in the documentation will the defense seek to exploit?

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Medical Abbreviations

(1 of 2)

• Use only universally accepted abbreviations, or those approved by your EMS system.

• You will be mastering medical terminology and abbreviations your entire career.

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Table 4-1 Commonly Accepted

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Table 4-2 Standard Charting

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Table 4-2 Standard Charting

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Table 4-2 Standard Charting

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Table 4-2 Standard Charting

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Table 4-2 Standard Charting

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Table 4-2 Standard Charting

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Medical Abbreviations

(2 of 2)

• A 48-year-old man is alert and oriented with a chief

complaint of severe chest pain and trouble breathing. He took two nitro without relief today, he is prescribed Lasix twice daily. He has no known allergies.

• A48 y / o M Pt A & Ox3, c / o CP and SOB. Took 2



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Legal Concerns

(1 of 5)

• Legal Concerns Include

1. Confidentiality

▪ The PCR contains information that is confidential and which cannot shared with unauthorized

individuals.

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Legal Concerns

(2 of 5)

2. Distribution

▪ Specific instances in which PCR information can be distributed include:

– To relevant health care providers (ED)

– CQI, medical oversight, billing

– Police, when needed for a investigation

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Legal Concerns

(3 of 5)

3. Refusal of Treatment

▪ Legal issues arise when a patient refuses care.

▪ Establish patient mental capacity and contact medical direction.

▪ Persuade the patient to accept care.

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Legal Concerns

(4 of 5)

3. Refusal of Treatment

▪ Document the following information:

– If the patient refused any or all assessment and the treatment offered

– The patient’s mental status in making the decision

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Legal Concerns

(5 of 5)

4. Falsification of PCR information

▪ Falsification compromises patient care.

▪ Can lead to loss of licensure and, possibly, criminal charges.

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Special Situations

(1 of 3)

5. Transfer of care

▪ Used when it is not possible to complete the full PCR and obtain signatures before leaving the facility.

▪ A type a special transfer-of-care form may be used.

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Special Situations

(2 of 3)

6. Multiple-casualty incidents

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Special Situations

(3 of 3)

7. Special Reports

▪ Suspected child or elder abuse

▪ Possible infectious disease exposure

▪ Injury to the EMS provider

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Alternative Documentation Methods

(1 of 5)

• Several formats for narrative documentation are represented by mnemonics.

– SOAP

– CHART

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Alternative Documentation Methods

(2 of 5)

• SOAP

– Subjective

– Objective

– Assessment

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Alternative Documentation Methods

(3 of 5)

• SOAPIE is a variation of SOAP

– Subjective

– Objective

– Assessment

– Plan

– Intervention

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Alternative Documentation Methods

(4 of 5)

• CHART

– Chief complaint

– History (includes SAMPLE)

– Assessment

– Rx (treatment)

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Alternative Documentation Methods

(5 of 5)

• CHEATED

– Chief complaint

– History

– Exam

– Assessment

– Treatment

– Evaluation

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Case Study Conclusion

(1 of 2)

Rory was eventually called to testify at the trial of the accused perpetrator. Fortunately, because the case

occurred a year after the call, Rory was able to rely on his thorough and accurate documentation to answer the

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Case Study Conclusion

(2 of 2)

The defense attorney questioned the meaning of several of the abbreviations Rory used in the PCR. Because Rory

always uses standard, accepted abbreviations, the defense attorney was unsuccessful in discrediting his

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Lesson Summary

• PCRs serve several purposes for the EMS system and Emergency Department.

• Good documentation should be accurate, concise, complete, and clear.

• Exercise cautiously in special reporting situations.

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Review Answers

(1 of 5)

1. Fill in the blank pulse rate c. Vital signs

Vital signs include

information about the

pulse, respirations, blood pressure, body

temperature, and oxygen level

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Review Answers

(2 of 5)

2. Fill in the Blank EMTs’ names a. Administrative information

Administrative information

includes times of events, EMS

unit number, run or call number, crew members’

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Review Answers

(3 of 5)

3. Fill in the Blank “Pt. c/o

headache on right side of head for 3 hours.”

d. Narrative

Narrative information gives more detailed information about the patient and

problem than allowed for in a checklist or data field format and includes the patient's chief complaint, history, and exam findings.

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