DocumentatioDocumentationn

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The prehospitalThe prehospital

care report is an care report is an

important important

medicalmedical and and

legallegal

document.document.

If you didn’t If you didn’t write it down... write it down...

……it didn’t it didn’t happen!happen!

Trending:Trending:

Comparing present Comparing present information about a patient’s information about a patient’s status with previously status with previously recorded information to recorded information to detect changes or trends.detect changes or trends.

Accurate Accurate andand

completecomplete

documentatiodocumentatio

n can n can

contribute to contribute to

quality quality

assurance.assurance.

Minimum Data SetMinimum Data SetMinimum Data SetMinimum Data Set

Minimum data set:Minimum data set:

The essential elements of The essential elements of patient and administrative patient and administrative data required for accurate data required for accurate and complete prehospital and complete prehospital data collection.data collection.

Patient Components Patient Components Age and genderAge and gender Chief complaintChief complaint Cause of injury/nature of illnessCause of injury/nature of illness Past medical historyPast medical history Signs and symptoms presentSigns and symptoms present Injury descriptionInjury description Level of responsiveness Level of responsiveness (AVPU)(AVPU) Pulse rate and blood pressurePulse rate and blood pressure

Patient Components continued Patient Components continued Respiratory rate, depth and effortRespiratory rate, depth and effort Lung soundsLung sounds Skin perfusion Skin perfusion (Capillary refill for patients <6 yrs)(Capillary refill for patients <6 yrs)

Skin color, temperature and conditionSkin color, temperature and condition Procedures performed on patientProcedures performed on patient Medications administeredMedications administered Response to treatmentResponse to treatment Document what the patient has done for themself and the effectDocument what the patient has done for themself and the effect

Administrative Components Administrative Components

Incident locationIncident location Date incident reportedDate incident reported Time incident reportedTime incident reported Date EMS unit notifiedDate EMS unit notified Time EMS unit notifiedTime EMS unit notified Time EMS unit respondedTime EMS unit responded Time of arrival at sceneTime of arrival at scene Time of arrival at patient’s sideTime of arrival at patient’s side

Administrative Components continued Administrative Components continued

Time EMS unit left sceneTime EMS unit left scene Time of arrival at destinationTime of arrival at destination Time of transfer of patient careTime of transfer of patient care Time when EMS unit back in serviceTime when EMS unit back in service Use of lights & siren Use of lights & siren (to & from scene)(to & from scene) Crew members respondingCrew members responding

All recorded All recorded

data must be data must be

ACCURATE!ACCURATE!

The Prehospital The Prehospital Care ReportCare ReportThe Prehospital The Prehospital Care ReportCare Report

Functions of the Prehospital Care Report

Functions of the Prehospital Care Report

Functions of the Prehospital Report Functions of the Prehospital Report

Helps ensure continuity of careHelps ensure continuity of care

Legal documentLegal document

Educational purposesEducational purposes

Administrative purposesAdministrative purposes

ResearchResearch

Evaluation and quality improvementEvaluation and quality improvement

The prehospital care The prehospital care report is a legal report is a legal document... document...

...and is ...and is considered considered

confidentialconfidential..

Documented InformationDocumented Information

Subjective informationSubjective information is not is not verifiable, but comes from verifiable, but comes from another’s point of view.another’s point of view.

Objective informationObjective information is is measurable or verifiable.measurable or verifiable.

Traditional Traditional FormatFormat

Traditional Traditional FormatFormat

Medical Reporting Format Medical Reporting Format Patient’s age and genderPatient’s age and gender

Chief complaintChief complaint

History of present illness or mechanism of injuryHistory of present illness or mechanism of injury

Pertinent past medical historyPertinent past medical history

Mental statusMental status

Medical Reporting Format continued Medical Reporting Format continued

Assessment or physical findingsAssessment or physical findings

Vital signsVital signs

Emergency care providedEmergency care provided

Patient’s response to emergency carePatient’s response to emergency care

Disposition of the patientDisposition of the patient

General Principles of the Narrative General Principles of the Narrative

Describe facts Describe facts (avoid conclusions)(avoid conclusions)

Record important observations of Record important observations of

the scenethe scene

Only use standard abbreviationsOnly use standard abbreviations

Spell words correctly Spell words correctly

(especially medical terms)(especially medical terms)

Write legibly and neatlyWrite legibly and neatly

Use printed text Use printed text (rather than cursive)(rather than cursive)

Other Other FormatsFormatsOther Other

FormatsFormats

Types of Written Formats Types of Written Formats SOAP methodSOAP method

Head-to-toe methodHead-to-toe method

Chronological methodChronological method

SSubjectiveubjective

OObjectivebjective

AAssessmentssessment

PPlanlan

Head-to-toe method:Head-to-toe method:

Findings documented as you Findings documented as you move from head to toe.move from head to toe.

Chronological method:Chronological method:

Documentation based on Documentation based on the the chronological the the chronological progress of the call.progress of the call.

EMS systems are

starting to utilize

computerized record

systems similar to an

electronic clipboard.

DistributionDistributionDistributionDistribution

Typical Report Distribution Typical Report Distribution Original retained by agencyOriginal retained by agency

Copy to receiving facilityCopy to receiving facility

Copy to state or local government agencyCopy to state or local government agency

Copy to medical directorCopy to medical director

Documentation Errors Documentation Errors versus versus

Patient Care ErrorsPatient Care Errors

Documentation Errors Documentation Errors versus versus

Patient Care ErrorsPatient Care Errors

Errors in patient Errors in patient

care must care must

always be always be

documented...documented...

……falsification of falsification of information in a information in a prehospital care prehospital care

report is report is illegal!illegal!

Correction of Correction of Documentation Documentation

ErrorsErrors

Correction of Correction of Documentation Documentation

ErrorsErrors

Patient describes pain as “crushing.”

Severity is rated as a 6 on a scale

of 1-10. Pt. stated the pain began 1

hr. prior to EMS notification arrival.

Pt. has a HX of hypertension and

angina. Current meds NTG.

JS

A properly corrected error.

One line through error One line through error to keep it legible, then to keep it legible, then initial.initial.

One line through error One line through error to keep it legible, then to keep it legible, then initial.initial.

Errors discovered after

a report is completed

should be corrected

with an ADDENDUM.

Documentation of Documentation of Patient RefusalPatient RefusalDocumentation of Documentation of Patient RefusalPatient Refusal

Refusal section of a prehospital care report.

Patient Refusal of Services

This is to certify that I, _________________ am refusing:__ Treatment__ Transport__ Other: __________________________________________

I acknowledge that I have been informed of the risk(s) involved, and hereby release the EMS personnel, their agency, the medical director, and medical control facility from all responsibility for any ill effects which may result from this action.

Signature:_______________________ Date: ___________

Witness:_________________ Witness:_________________

Even if the patient signs a Even if the patient signs a refusal form... refusal form...

...a prehospital ...a prehospital patient care reportpatient care report

MUSTMUST be be completed.completed.

Patient Refusal Documentation Patient Refusal Documentation

A completed and signed refusal formA completed and signed refusal form

That the patient was informed of the possible adverse effects of refusalThat the patient was informed of the possible adverse effects of refusal

Have a witness sign the form, a police officer, bystander or family memberHave a witness sign the form, a police officer, bystander or family member

If patient refuses to sign, have a witness sign attesting refusalIf patient refuses to sign, have a witness sign attesting refusal

Special SituationsSpecial SituationsSpecial SituationsSpecial Situations

Multiple-Casualty Incidents

Multiple-Casualty Incidents

A triage tag may be used in an MCI.

Special Situation Special Situation ReportsReports

Special Situation Special Situation ReportsReports

Special Situation ReportsSpecial Situation Reports

Infectious disease exposureInfectious disease exposure

Injury to EMS personnel or bystandersInjury to EMS personnel or bystanders

Equipment damage or malfunctionEquipment damage or malfunction

Vehicle crashes involving the EMS unitVehicle crashes involving the EMS unit

Patient refusalsPatient refusals

Crime scenesCrime scenes

Hazardous materials incidentsHazardous materials incidents

SU

MM

AR

YS

UM

MA

RY Minimum Data SetMinimum Data Set

The Prehospital Care ReportThe Prehospital Care Report

Documentation of Patient Documentation of Patient RefusalRefusal

Special SituationsSpecial Situations