Documentation and Communication

Documentation and Communication

OpeningCase Documentation

Warm up your pens. Perry is having chest pain.

Perry is 50 years old He has a history of angina and has experienced heart attacks in the past. He is a fairly stalwart individual and does not like to ask for help. My chest really hurts. It feels like I have an elephant standing on it. I just can’t catch my breath.

Perry I took two of my nitroglycerin tablets, but it just won’t go away. I also have a bad headache. Perry discretely shows you a bottle of sildenafil he borrowed from a friend. He admits his discomfort started after lunch, during some strenuous physical activity. He won’t elaborate.

Perry This pain is about a “9” on a scale from 0 to 10. It goes into my shoulder, too. I didn’t black out or vomit. Perry has no allergies. He smokes three packs of cigarettes a day. His wife is traveling today, but he has a cell phone contact for her and he would like you to call her.

Narrative Write down a history of the present illness for Perry.

Sick or Not-yet-sick? SICK? Why? or NOT YET SICK?

Once upon a time…..

Introduction Two sections to this lesson: • Written documentation • Verbal reports

Introduction Critical Skills As important as other skills in the profession

Documentation • Factual evidence • Core principle of professionalism and accountability • Must not be governed by a “minimum standard”

Documentation • Should reflect high levels of professionalism worthy of respect • Proper documentation process creates a protective, legally defensible report

Documentation • Write prehospital reports with the jury in mind • Your PCR should not be a legal handicap—it should be your legal shield

Street Secret A working ballpoint pen with black ink is an essential piece of equipment for a paramedic • Carry a few extra and a small notepad in your pocket

Foundation of Documentation • Pertinent scene size-up information • The assessment • Medical history • Vital signs

Foundation of Documentation • Physical examination • Treatment provided • Continued assessments “If it wasn’t written, it wasn’t done!”

Specific Expectations • Agency requirements • Jurisdictional considerations • State obligations • HIPAA (Health Information Portability Accountability Act)

Professional Accountability

Professionalism • Documentation is an extension of your professionalism. • Judged by • Language • Tone • Grammar • Spelling

PCRs • Clinicians, physicians, nurses, social workers, and other allied health professionals all have access to your PCRs

PCRs • Nonclinical personnel who have access to your PCRs: • Billing agents • Insurance auditors • Federal investigators and law enforcement • Risk managers • EMS administrators • Attorneys • Expert witnesses

Documentation Is Evidence • Judged reliable and truthful • Recorded contemporaneously • Credible written testimony

Documentation Is Evidence • Factual credibility is enhanced when it is: • Timely • Concise • Accurate • Organized • Properly punctuated • Correctly spelled

Street Secret Be professional: • spelling, • diction, and • grammar… make all the difference. Want respect?

Poor Documentation May implicate you in certain circumstances revealing • Omission of required treatments • Violations of protocol • Lack of vital and supportive documentation

What’s wrong with this form?

Errors A misteak mistake should be crossed out and initialed.

Well-Written Reports • Compel the reader to appreciate your decision-making • Provide rationale supporting the protocol and treatment plan you followed • Include imagery involving the senses

What is the purpose of including the imagery of sight, touch, smell, and feel in documentation? A. To show that the patient’s neurological system is intact B. To convey an accurate picture of events C. To promote professionalism through language D. To show that it was written and it was done

Hallmarks of a Well-Written PCR

Hallmarks of a Well-Written PCR • Factual • Well-formatted • Accurate • Succinct • Organized

Hallmarks of a Well-Written PCR • Respect for the prehospital provider’s accountability for proper documentation • Not simply with regard to the patient

Organizational Framework Poor organization = Poor impression = Poor care provided

Organizational Framework Good organization = Thorough assessment/treatment = Good care provided (and is defensible)

Narratives

Narratives • Traditional narratives can be fragmented and a collection of disjointed facts

Narratives Two commonplace frameworks: • CHART • SOAP (or SOAPIER)

Standardized Content • ALL NARRATIVES MUST CONTAIN: • Age • Gender • Conditions • Chief complaint • Associated complains • Relevant past medical history • Medications and allergies

Standardized Content • ALL NARRATIVES MUST CONTAIN: • Assessment findings • Treatment • Responses • Reassessments • Transportation/disposition of the patient

Objective Information • Objective notations are observed • Observable clinical signs • Physiologic data • Technology-derived data • Descriptive observations • Measurable comparatives

Subjective Information • Subjective information can be remembered as spoken: • Feelings • Opinions • Use only subjective information collected • Use quotes as needed

Why is objective information important? A. It includes the patient’s medications B. It’s factual and recorded by a trained observer C. A third party reports the information D. It describes events leading to the 9-1-1 call

Street Secret • Document assessments from head to toe

CHARTFormat

CHART FORMAT C = Chief complaint H = History A = Assessment R = Treatment T = Transfer/transport

C = “Chief complaint” of the patient or the reason EMS was summoned CHART Framework

CHART Framework • H = History. Symptoms: • O: Onset • P: Provocation or Palliation • Q: Quality • R: Region or Radiation • S: Severity • T: Time

Documentation and Communication