Emergency Medical Responder
Emergency Medical Responder
First on Scene
First on Scene
CHAPTER
TENTH EDITION
Principles of Effective
Documentation
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.
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.
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.
Topics
Patient Care Reports
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
•
Documentation is a permanent record
of provided care.
•
Reports may be handwritten or
electronic and recognized by different
titles.
Run reports
Patient care reports
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
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
Patient Care Reports
•
Elements of the PCR
Run data
•
Information about call
Patient data
•
Patient information
•
Sections of the Report
Fill-in
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
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)
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
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.
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
•
The quality of your documentation is
reflective of the care you provide.
•
How can data collection benefit EMS?
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
•
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
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
Methods of Documentation
•
Laptop computers
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
•
Data-enabled cellular devices
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?
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
Summary
•
PCR main categories
Run data
Patient data
•
Completed using combination of fill-ins,
check boxes, and narrative areas
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.
Summary
•
Patient care documentation completed
Traditional paper-based forms
High-tech handheld computers
Data-enabled cellular devices
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
Review Questions
1.
What is the purpose of the PCR?
2.
What elements are typically included
in the PCR?
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