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Documentation / EMSCHARTS

Documentation / EMSCHARTS. What is documentation?. A permanent legal document which provides a comprehensive account of information about the individual’s health care status. . Why document?. Clinical Legal document which you may have to defend in court one day, years from incident

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Documentation / EMSCHARTS

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  1. Documentation / EMSCHARTS

  2. What is documentation? • A permanent legal document which provides a comprehensive account of information about the individual’s health care status.

  3. Why document? • Clinical • Legal document which you may have to defend in court one day, years from incident • Data and statistics • Medical record which must be treated confidentially, as defined by HIPPA regulations • Education • Quality Management

  4. Guidelines • If it is not written down, it was not done. • If it was not done, do not write it down.

  5. Characteristics of Strong Documentation • Complete • Clear • Concise • Accurate (including spelling) • Objective • Timely

  6. Objective vs. subjective • Objective- intended to be unbiased • Subjective- usually based on fact, but it is someone’s interpretation of a fact Ex: a. The patient was in a lot of pain. b. The patient had mid-sternal chest pain which radiated into his back 8/10, sharp, consistent, negative increase in pain on palpation.

  7. Approaches to Narrative (CHART System) • CHART- Chief Complaint, History, Assessment, Rx(Treatment), Transport • Other options: SOAP (Subjective findings, Objective findings, Assessment, Plan)

  8. Chief complaint and history (C,H)- What you are told • Chief Complaint • History of Present Illness: OPQRST • Past Medical History: SAMPLE

  9. What is a chief complaint? • “Reason EMS has been called, usually recorded in patient’s own words” • “Some cases the patient’s chief complaint is different from the reason EMS was called” Source: Emergency Medical Technician EMT in Action, 2nd Edition, Barbara Aehlert, page 306, Published by McGraw-Hill, New York, NY, 2011

  10. Assessment (A)- What you see/feel/hear • Trauma -pt. appearance, surroundings, position -head, nose, eyes, ear, throat -neck -chest -abdomen, pelvis -extremities • Cardiopulmonary -pt. appearance, surroundings, position -neck- jugular veins, trach deviation -chest – lung sounds, respiratory rate -extremities- edema, pms -other- oxygen sat level • AMS -pt. appearance, surroundings, position -mental status (AVPU, orientation, memory, LOC?) -pupils -trauma assess

  11. (Rx,Transport)- What you did • What was done for the patient? • How was patient moved to stretcher? To ambulance? • How did the patient respond? • Improvement or deteriorating condition during transport? • Where was patient brought? Who assumed care?

  12. Principles of Writing the Narrative • Paint a picture • Try to be chronological • Include pertinent negatives • Describe, don’t conclude i.e. “patient was involved in MVA where he had damage to rear of vehicle” vs. “patient was rear-ended” • Record important observations on scene- i.e. damage to car, presence of weapons, pill bottles • Only use standard abbreviations • Include changes in pt. condition after treatment/during transport • Identify the source of information • Check spelling/grammar • Do not document interventions by medics

  13. Documenting RMA’s • More is necessary

  14. High-risk Refusals • Abdominal Pain • Chest Pain • Electrical shock • Poisoning • Pregnancy related complaints • Water-related incidents • Falls >10 ft • Head Injury • Vehicle roll-over • High speed MVA • Auto vs. pedestrian or auto vs. bicyclist • Motorcycle crash speeds >20 MPH • Pediatric patient with medical complaint

  15. Bare Necessities • Patient name, age, DOB • Hx, Rx, allergies • Two complete sets of vitals (or a good reason why not) • Mental status findings • Physical exam findings • Reason for refusal • Signed refusal form • Advice given by BLS • Acknowledgement that pt understands risks/dangers of refusal and possible outcomes

  16. Patient was assessed • Trauma: rapid physical assessment, focused physical assessment, DCAP-BTLS • 6 vitals signs: lung sounds, pulse, respiratory rate, blood pressure (cap refill <3 years old), pupils, skin condition

  17. Back to basics • Respiratory Distress- lung sounds, respiratory rate, use of accessory muscles • AMS- normal mental state, how long has patient been altered, last seen normal, stroke test • Psych- threaten themselves or others, physically violent • Allergic reaction- known allergies, hives, itchiness, redness, difficulty breathing, meds

  18. Set up of EMScharts • Charting by exception

  19. EMSCharts Guidelines • All charts are to be entered within 24 hours of the call • All PCR’s will be QA’ed within 72 hours • All PCR’s should be entered at station or in ambulance

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