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Documentation

Documentation

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Documentation

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  1. Documentation

  2. Outline • Overview value of excellent documentation • Define, discuss, review SOAP notes • Review how it should look in MEMSRR • Questions and discussion

  3. WHY? • Patient Legacy • Continuity of Care • Legal Document • Billing

  4. MEMS • MEMS patient/run record will be legible and thoroughly completed for each call or for each patient when more than one patient is involved in a call. This document is our legacy of patient care and holds information valuable to hospital providers. Services are encouraged to leave a completed copy of the patient/run report at the hospital before they leave. In rare circumstances, when it is not possible to complete this record before leaving the hospital, the services may provide the hospital with a Maine EMS approved, one page, patient care summary. THIS DOCUMENT DOES NOT REPLACE THE COMPLETED RUN REPORT. Services must complete this report and make the report available to the hospital as soon as possible.

  5. BiLLING • Be clear • Emergency vs. Transfer • Transport? • All procedures, treatments, interventions and medications need to be listed • Spelling, Grammar, Abbreviations

  6. SOAP • S ~ Subjective ~ What happened? • O~ Objective ~ What did you find? • A ~ Assessment ~What do you think? • P ~ Plan ~ What did you do?

  7. The Call Called to XYZ Office for a woman who fainted

  8. Subjective • Tell the Story • Include: • Age • Chief Complaint • MOI/NOI • What, when, where, how? • SAMPLE…..OPQRST • Pertinent meds and medical history

  9. Ambulance 7 responded for a 40 year old female who had a syncopal episode from a standing position. Patient reports she was at work and began to feel nauseous. Walked into break room and passed out on floor. Coworkers report pt. slumped forward onto recliner then slid onto carpeted floor. No obvious head or neck involvement and no significant traumatic mechanism. No seizure type activity noted. Pt. reports waking on the floor cold and shivering. Pt. moved to couch with assistance. Pt. denies head, neck, chest or back pain, sob, headache, vomiting, blurred vision, numbness, or tingling in extremities. Pt. does report mild dizziness and ongoing weakness. Coworkers called 911 for assistance.

  10. Objective • Get Technical… do the Investigation • Include: • LOC • Head to toe report with emphasis on appropriate detailed assessment • Vitals including skin • + ( positive findings) and – (pertinent negatives) • Some overlap

  11. Upon initial contact, patient lying on couch in break room, alert and oriented to name, place, time and event. Skin warm and dry with normal color and tone. Mild muscle tremors (shivers) in arms and legs. Pt. does report feeling cold. Head normocephalic without abnormality on visualization or palpation. Neck midline and intact without pain on palpation or movement. Thoracic, lumbar and sacral spine intact without pain on palpation or spontaneous movement. Chest intact with equal expansion, unremarkable on visualization and palpation. Lung sounds clear and equal bilaterally with normal tidal volume. Breathing pattern normal. No odor on breath noted. Abdomen soft, non- tender, atraumatic and unremarkable on visualization and palpation to all quadrants, without masses or rigidity noted.

  12. Pelvis and hips stable and intact without pain or crepitus on palpation anterior or lateral. Incontinent to urine. Legs and knees intact and atraumatic. Arms are intact and atraumatic. No language barrier existed between patient and providers. Neurological Exam: Pt.’s pupils equal, round and reactive to light. Pt. does not present with observable short or long term memory loss or confusion. Major motor neuros intact. Gross sensory assessment intact with normal sensation throughout. Assessment revealed no abnormal neurological findings. CiSS negative. All observable neurological assessments remained unchanged during and after transport to hospital.

  13. Assessment • What do you think is going on with the patient • Unsure? List what you think as possibilities

  14. Plan • Details of interventions and how the patient responded • Include : • Treatments (splints, nebs, CPAP, etc…) • Medications (02, Normal Saline, D50, etc…) • Interventions ( Monitor, IV/INT, Bg….)

  15. Pt. transported non-emergent to XYZ emergency room. Pt. transported without change in status or level of consciousness. Patients treatment plan included full secondary assessment, detailed neurological examination, vital signs, cardiac monitoring, 12 lead, pulse oximetry, Bg, IV left hand tko and supplemental oxygen. Following hand off report to staff, patient left in hospital bed with rails up and staff in attendance.

  16. Thanks! • Remember if you didn’t write it, it didn’t happen • Documentation is patient care! • Be thorough and take pride in what you write • Use SOAP as a guideline • Make the most of the available drop down boxes in MEMSRR!