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Documentation. ECA Temple College. Purpose of Documentation. Patient Care The most important reason Record for other health care providers to reference at a later date Becomes part of patient record for later use Legal Record May be used in court proceedings

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  1. Documentation ECA Temple College

  2. Purpose of Documentation • Patient Care • The most important reason • Record for other health care providers to reference at a later date • Becomes part of patient record for later use • Legal Record • May be used in court proceedings • May be your sole source of reference

  3. Other Uses • Medical Audit • Run Review Conferences • Other Educational Forums • Quality Improvement • Evaluate and improve individual performance • Evaluate and improve system quality • Billing and administration • Gather data necessary for economic and regulatory purposes • Research • Studies to improve patient care and system performance

  4. Types of written reports • Traditional written form with check boxes and a section for narrative. • Computerized version where information is filled in by means of an electronic clipboard or a similar device.

  5. Did you know information “missing” in your pre-hospital report may prove more valuable to an attorney than the information that is actually written in the report….“The missing Protocol”

  6. Sections of a report • Run Data • Patient Data • Narrative

  7. Run Data • Date • Times • Name of service • Unit number • Names of crew members

  8. Patient Data • Patient name • Address • Date of birth • Insurance information • Sex • Age • Nature of call or mechanism of injury

  9. Patient Data • Location of patient • Treatment administered prior to arrival of ECA • Signs and symptoms • Care administered by first responders • Baseline vital signs • SAMPLE history • Changes in condition.

  10. Issues of Credibility • Misspelled words • Illegible handwriting • Poor writing skills • Added information well after the event…


  12. Narrative Styles • SOAP • CHARTE • Body Systems • Chronological

  13. SOAP(E) • Subjective • Objective • Analysis (or Assessment) • Plan • Enroute (or changes) Liquid SOAPE

  14. Subjective • Also called the history of the present illness/injury. • Contains the patient’s symptoms or complaints. • In the patient’s own words, but skillfully condensed. • Formally, contains the past medical history, current medications and allergies.

  15. Objective • Also called the physical examination. • Contains your observations (signs). • Formally, contains the vital signs. • Avoid subjective terms: normal, poor, good, or WNL.

  16. Analysis • Also called the clinical impression or presumptive diagnosis. • It is a summary of the objective and subjective sections. • It is not a formal diagnosis • Often includes a triage category.

  17. Plan • The actual plan and delivery of patient care. • Not what you wished you had done. • Rescue before resuscitation, resuscitation before definitive treatments. • Sometimes responses to treatment are listed.

  18. Enroute • Also called changes or response to treatment (especially by non-transporting first responders).

  19. Narrative • Written account of what occurred. • Include information that is not included in other sections of the report. • Be Objective • The patient was drunk. VS • The patient had slurred speech, smelled of alcohol, was not able to make coordinated movements, and admitted to drinking alcohol. • Allow reader to draw the desired

  20. Patient Information • Minimum information gathered at time of ECA's initial contact with patient on arrival at scene, following all interventions and on transfer of care or arrival at facility. • Chief complaint • Level of consciousness (AVPU) - mental status • Systolic blood pressure for patients greater than 3 years old • Skin perfusion (capillary refill) for patients less than 6 years old • Skin color and temperature • Pulse rate • Respiratory rate and effort • For every reassessment, record time and findings.

  21. Patient Care Errors • You are human, you will make mistakes. • Learn from them and do not make them again • Be honest and forthcoming about your error

  22. Falsification Issues • Error of omission or commission occurs • Do not try to cover it up. • Document what did or did not happen • What steps were taken (if any) to correct the situation. • Falsification of information • Suspension or revocations of certification • Removal of ability to practice in system • Specific areas of difficulty • Vital signs - document only the vital signs that were actually taken. • Treatment - if a treatment like oxygen was overlooked, do not chart that the patient was given oxygen.

  23. Correction of Written Errors • Errors discovered while the report form is being written • Draw a single horizontal line through the error, initial it and write the correct information beside it. • Do not try to obliterate the error - this may be interpreted as an attempt to cover up a mistake. • Errors discovered after the report form is submitted • Preferably in a different color ink, draw a single line through the error, initial and date it and add a note with the correct information. • If information was omitted, add a note with the correct information, the date and the EMT-Basic's initials.

  24. Correction Examples During writing Mr. Smith complains of shortness of breath, chest pain, and jaw arm pain After completed Mr. Smith complains for jaw pain. JDF, 10/12/06 Addendum: Mr. Smith complained of arm pain not jaw pain. This was discovered after reviewing the original report. This addendum is intended to correct this error. Jeff Fritz 10/13/2006 11:20 am

  25. Patient Refusal • Competent adult patients have the right to determine what does and does not occur to their body • Thus they have the right to refuse all or part of the care you offer.

  26. Refusals • Perform a complete and detailed assessment • Ensure the patient is able to make a rational, informed decision, e.g., not under the influence of alcohol or other drugs, or illness/injury effects. • Inform the patient • What is wrong with the patient (from detail assessment) • Why he should go to the hospital (what care can they provide) • What may happen to him if he does not (consequences) • Alternatives to transport and or treatment • Consult medical direction as directed by local protocol. • Try again to persuade the patient to go to a hospital.

  27. Before you leave the scene • If the patient still refuses, document any assessment findings and emergency medical care given, then have the patient sign a refusal form • Have a family member, police officer or bystander sign the form as a witness. • If the patient refuses to sign the refusal form, have a family member, police officer or bystander sign the form verifying that the patient refused to sign. • Inform patient of your willingness to return

  28. Document the Refusal • Your assessment findings • What you told the patient • What is wrong, why he should go, consequences, alternatives, and your willingness to return. • The patient understood all of the above • What the patients comments were • Your attempts to convince the patient to go

  29. Mass Casualty Incidents • The local MCI plan should have some means of recording important medical information temporarily, e.g., triage tag, that can be used later to complete the form. • The standard for completing the form in an MCI is not the same as for a typical call. The local plan should have guidelines.

  30. Written Report • When information of a sensitive nature is documented, note the source of that information, e.g., communicable diseases. • Be sure to spell words correctly, especially medical words. If you do not know how to spell it, find out or use another word. • Include pertinent negatives. • If you expect to find something and it is not there • i.e. patient with chest pain who is not short of breath

  31. Written Report • Confidentiality – • the form itself and the information on the form are considered confidential. • Only those with a need to know should see it • Billing • Other health care providers who will care for patient • This does not include other members of your organization

  32. Common Errors • Misspelled words • Poor grammar • Illegible handwriting • Unknown or improper abbreviations • Incomplete forms

  33. Examples • pateint • CP, TD, PERRLA • patient were bedridden • patient complains of laceration thigh pain

  34. Report Example • Subjective: 59 year old male complaining of substernal chest pain that radiates to left arm and jaw. Onset around 15:30 after argument with son. Pain not improved or relieved with position or breathing changes. Pain is described as dull pressure and rated at 8/10. Pt also complains of SOB and weakness. Pt denies nausea, vomiting, dizziness. History: HTN. Allergies: NKDA. Medications: Procardia 30mg/day.

  35. Objective: Pt sitting in chair in obvious pain. Pt’s fist rubbing chest. Mental Status: Awake, responds appropriate to questions Skin: cool, diaphoretic. HEENT: 0 wounds, PEARL, No accessory muscle use, + JVD, Bruits present. CHEST: 0 wounds, bilateral basilar rales, non tender, no discoloration. ABD: soft, non tender, no masses, no wounds. PELVIS: deferred. EXT: moves all extremities, + pulse, +sensory,

  36. Flow chart

  37. Assessment: MI – Urgent • Plan: Oxygen via NRB @ 15 lpm, vital signs, ASA 324 mg PO, nitroglycerin 0.4 mg SL, repeat vital signs, prepare for transport, verbal report given to M. Smith. Pt transported with M12

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