• No results found

Chapter 8

N/A
N/A
Protected

Academic year: 2020

Share "Chapter 8"

Copied!
32
0
0

Loading.... (view fulltext now)

Full text

(1)

Emergency Medical Responder

Emergency Medical Responder

First on Scene

First on Scene

CHAPTER

TENTH EDITION

Principles of Effective

Documentation

(2)

Copyright © 2016, 2011, 2009 by Pearson Education, Inc. All Rights Reserved

Emergency Medical Responder: First on Scene, 10/e Christopher J. Le Baudour | J. David Bergeron

Objectives

1.

Define the following terms:

a.

Continuity of care

b.

Electronic documentation

c.

Minimum data set

d.

Patient Care Report (PCR)

2.

Explain the purpose of the patient care

report.

3.

Describe the elements of a typical

patient care report.

(3)

Objectives

4.

Describe the minimum data set

required for the documentation of

patient care.

5.

Explain the procedure for correcting

errors made during documentation.

6.

List various tools used to document

patient care in the field setting.

(4)

Copyright © 2016, 2011, 2009 by Pearson Education, Inc. All Rights Reserved

Emergency Medical Responder: First on Scene, 10/e Christopher J. Le Baudour | J. David Bergeron

Objectives

7.

Demonstrate the ability to accurately

document a simulated patient

encounter.

8.

Properly correct an error made during

documentation.

(5)

Topics

Patient Care Reports

(6)

Copyright © 2016, 2011, 2009 by Pearson Education, Inc. All Rights Reserved

Emergency Medical Responder: First on Scene, 10/e Christopher J. Le Baudour | J. David Bergeron

(7)

Patient Care Reports

Documentation is a permanent record

of provided care.

Reports may be handwritten or

electronic and recognized by different

titles.

Run reports

Patient care reports

(8)

Copyright © 2016, 2011, 2009 by Pearson Education, Inc. All Rights Reserved

Emergency Medical Responder: First on Scene, 10/e Christopher J. Le Baudour | J. David Bergeron

(9)
(10)

Copyright © 2016, 2011, 2009 by Pearson Education, Inc. All Rights Reserved

Emergency Medical Responder: First on Scene, 10/e Christopher J. Le Baudour | J. David Bergeron

Patient Care Reports

Reasons for accurate and complete

documentation

Continuity of care

Education

Administration

Quality assurance

(11)

Patient Care Reports

Elements of the PCR

Run data

Information about call

Patient data

Patient information

Sections of the Report

Fill-in

(12)

Copyright © 2016, 2011, 2009 by Pearson Education, Inc. All Rights Reserved

Emergency Medical Responder: First on Scene, 10/e Christopher J. Le Baudour | J. David Bergeron

Patient Care Reports

Information in narrative should be

objective rather than subjective.

Objective

Straightforward facts

Subjective

Up for interpretation

(13)

Patient Care Reports

Minimum Data Set

Time incident was reported to 911

Time of dispatch

Time of arrival at patient's location

Time patient was transported from

incident location

Time patient arrived at destination

(e.g., hospital, aid station)

(14)

Copyright © 2016, 2011, 2009 by Pearson Education, Inc. All Rights Reserved

Emergency Medical Responder: First on Scene, 10/e Christopher J. Le Baudour | J. David Bergeron

Patient Care Reports

Minimum Data Set

Time patient care was transferred to

more advanced providers

Patient's chief complaint

Patient's vital signs

Patient's demographics

(15)

Patient Care Reports

Correcting Errors

Cross out incorrect item with single line,

initial it, write correct number beside or

above it.

Never completely cover incorrect

information.

(16)

Copyright © 2016, 2011, 2009 by Pearson Education, Inc. All Rights Reserved

Emergency Medical Responder: First on Scene, 10/e Christopher J. Le Baudour | J. David Bergeron

(17)

Think About It

The quality of your documentation is

reflective of the care you provide.

How can data collection benefit EMS?

(18)

Copyright © 2016, 2011, 2009 by Pearson Education, Inc. All Rights Reserved

Emergency Medical Responder: First on Scene, 10/e Christopher J. Le Baudour | J. David Bergeron

(19)

Methods of Documentation

Paper forms

PCR forms filled out by hand

Computer-scan forms

PCR forms completed by hand

Fill-in-the-bubble format can be scanned

into computer for information

(20)

Copyright © 2016, 2011, 2009 by Pearson Education, Inc. All Rights Reserved

Emergency Medical Responder: First on Scene, 10/e Christopher J. Le Baudour | J. David Bergeron

Methods of Documentation

PDAs or handheld computers

Specialized software allows emergency

care professionals to enter PCR

information.

Information then downloaded to

(21)

Methods of Documentation

Laptop computers

(22)

Copyright © 2016, 2011, 2009 by Pearson Education, Inc. All Rights Reserved

Emergency Medical Responder: First on Scene, 10/e Christopher J. Le Baudour | J. David Bergeron

(23)

Methods of Documentation

Data-enabled cellular devices

(24)

Copyright © 2016, 2011, 2009 by Pearson Education, Inc. All Rights Reserved

Emergency Medical Responder: First on Scene, 10/e Christopher J. Le Baudour | J. David Bergeron

Think About It

How might electronic PCR be useful

during an emergency with multiple

patients?

(25)
(26)

Copyright © 2016, 2011, 2009 by Pearson Education, Inc. All Rights Reserved

Emergency Medical Responder: First on Scene, 10/e Christopher J. Le Baudour | J. David Bergeron

Summary

Patient care documentation is

important.

Continuity of medical care to legal

proceedings

Becomes permanent part of patient's

medical record

Can be used by EMS organizations to

improve overall quality of emergency

services

(27)

Summary

PCR main categories

Run data

Patient data

Completed using combination of fill-ins,

check boxes, and narrative areas

(28)

Copyright © 2016, 2011, 2009 by Pearson Education, Inc. All Rights Reserved

Emergency Medical Responder: First on Scene, 10/e Christopher J. Le Baudour | J. David Bergeron

Summary

Each PCR has a minimum data set as

defined by U.S. Department of

Transportation.

Documentation errors should be

corrected without trying to obscure

erroneous information.

Put a single line through mistake, enter

correct information above or beside it,

initial change.

(29)

Summary

Patient care documentation completed

Traditional paper-based forms

High-tech handheld computers

Data-enabled cellular devices

(30)

Copyright © 2016, 2011, 2009 by Pearson Education, Inc. All Rights Reserved

Emergency Medical Responder: First on Scene, 10/e Christopher J. Le Baudour | J. David Bergeron

(31)

Review Questions

1.

What is the purpose of the PCR?

2.

What elements are typically included

in the PCR?

(32)

Copyright © 2016, 2011, 2009 by Pearson Education, Inc. All Rights Reserved

Emergency Medical Responder: First on Scene, 10/e Christopher J. Le Baudour | J. David Bergeron

Please visit

www.bradybooks.com

and follow the Resource Central

links to access content for this

Figure

Figure 8.1   Example of a typical paper-style patient care report (PCR) form.
Figure 8.2   Electronic documentation of an emergency call is becoming more common.
Figure 8.4   A typical electronic tablet used for documenting patient care.

References

Related documents

CRIME SCENE INTEGRITY – FIRST RESPONDER RESPONSIBILTIES & PRECAUTIONS It shall be the primary responsibility of the first responding officers on a crime scene to identify

Entrepreneurial Mindset Entrepreneurial Motivation Entrepreneurial Behaviors With an appreciation for the opportunities and challenges of strategic decision making, you can

The controller attempts to minimize the error by adjusting the process through use of a manipulated variable, in our case it is the radio signal that is being sent to

CONDITIONS UNDER WHICH FDA GENERALLY DOES NOT INTEND TO TAKE REGULATORY ACTION REGARDING STABILITY TESTING AND EXPIRATION DATE REQUIREMENTS ..... Current Good

The data on the indexes of Business competitiveness (BCOM), Business Sophistication (BSUF), Innovations (INOV), Governance of the Corporate and Political Institutions

Thus, the main objectives are to (1.1) identify patterns (recurrent issues) of the implementation of rural governance principles in the case of the top-down initiated LEADER LAGs

The inequalities characterizing critical function spaces in terms of Sobolev’s embedding such as Sobolev-Lorentz spaces, Sobolev-Morrey spaces, Besov spaces, Triebel-Lizorkin spaces

It is worth of mentioning, in this context, that the proof by Vishik [18] of the global existence for (1) in the borderline Besov spaces is based on a refined result on the action