Emergencies and Documentation

1. Emergencies and Documentation The Center For Life Enrichment Staff Training October 2009

2. Emergencies

3. Emergency Situations 911 • If you are faced with an emergency situation, the most important thing to remember is to stay CALM. Sometimes staying calm is easier said than done; just remember you will accomplish very little and may even cost yourself valuable time, if you panic during an emergency. • One technique that will help prepare you for an emergency is to run drills in your program area; act out different scenarios, such as: What if there were a fire in the building? • How to prepare yourself: • Talk about emergency preparedness with your co-workers and clients • Familiarize yourself with the Emergency Preparedness Plan at TCLE • Know the emergency routes in the county • Know the radio stations to listen to in the event of an emergency

4. Time • Time is usually crucial when administering emergency medical care. If there is a medical situation that you cannot remedy or help, your quick and immediate contact with a 9-1-1operator can help medical technicians get there sooner. If you panic, you will definitely complicate an already stressful situation; people surrounding you are also likely to panic, if they see you upset.

5. Remember • Be conscious of your tone of voice and how fast you speak, when relaying information to a 9-1-1 operator. • It is important to speak slowly and calmly to avoid having to repeat information; if you remain calm, valuable time will be saved. Be knowledgeable about your location, phone numbers, and names of those injured. • Take a deep breath prior to placing a call to 911; this will help you stay focused and speak slowly.

6. When Faced with an Emergency • In the event of a true emergency, contact 911. • If you are unsure about whether or not to call 911, contact a program coordinator and/or the nurse for guidance. • If emergency personnel are called, TCLE staff should gather consumer information for emergency responders, i.e. IP cover sheet, current medication list, etc. • TCLE staff should direct other clients away from the scene. • If a consumer is taken from the facility for emergency treatment, TCLE staff should accompany the individual until relief arrives (i.e. family, group home staff, etc.).

7. Accident Procedures • Any accident involving a TCLE vehicle, must be reported immediately to the Transportation Department. If the transportation coordinator and assistant are unavailable, contact the main office at TCLE to report the accident. • If you are in an accident involving another vehicle, the following information must be exchanged: • Driver’s name • Address • Phone number • Insurance information • Any accident involving a TCLE vehicle, must be reported to the police. • If a consumer is hurt, administer first aid based on your level of training. If a consumer requires further medical assistance, call 911. Then contact the main office at TCLE with a listing of consumer names and information about medical conditions. • Always know where the vehicle registration is kept in the vehicle; you will need to produce this document, if you are ever in an accident. • For more information, contact: • Karen Gardner- 301-373-8100*836 (cell)301-481-8600 • Debbie Kellam- 301-373-8100*826 (cell)240-434-3974

8. Documentation

9. Guidelines for Documentation • Document accurately:Record the facts, not opinions. Never falsify records to cover up a negligent act. • Document completely: You will find it difficult to prove that you provided a service, if you do not documented it. • Note the Time: Be specific about the time something happens. This is especially important when you are writing an incident report or documenting in a communication book. Also, document information as soon as possible; you are more likely to remember important details this way! • Document objectively:Record exactly what you see, hear, and do. Remember to document data you witness yourself, or data from a reliable source. When you include information reported by someone else, cite your source. • Forms & Ink: Be sure to use the correct form for the situation at hand. Be sure to use blue or black ink. • Signature:Be sure to sign all reports and forms. • Mistakes: Do not use white-out; if you make a mistake, cross out the word and initial it.

10. -Documentation-Seizure Observation Record • A “Seizure Observation Record” should be completed when a client has a seizure. The staff observing the seizure should complete the form. Take special note of the length of the seizure and the individual’s physical characteristics. The completed form should be submitted to the client’s program coordinator. • Seizure forms are located in the main office at TCLE. If you are offsite, make sure this form is available to you at all times. • In some cases it may be beneficial to keep a “Seizure Calendar.” On the calendar, staff would mark each day the client has a seizure; using this form, the data can quickly be reviewed for patterns. Please see a program coordinator for this form.

11. -Documentation-Incident Reports and Unusual Occurrence Forms • Incident Reports and Unusual Occurrence Forms should be completed by staff observing an unusual occurrence. Examples include: • Minor injury (non-work related) • Client disputes • Unusual behaviors • Property destruction • Marks on the body • If a client has a behavior plan, make sure you are documenting behavioral concerns on the appropriate forms (i.e. ABC Data sheet, etc). • Incident Reports and Unusual Occurrence Forms are located in the main office at TCLE. If you are offsite, make sure these forms are available to you at all times. • When in doubt, document it!

12. -Documentation-Workers’ Compensation Injury Form • As soon as an injury occurs, you must notify Human Resources and your supervisor. • After notification, seek whatever medical or emergency care is needed for your injury. • A Workers’ Compensation Injury Form should be completed and returned to Human Resources within 24 hours of an injury. • If you are seeking treatment, the last page of this form should be completed by the treating physician. • Injury forms are located in the main office at TCLE. If you are offsite, make sure this form is available to you at all times.

13. Remember: If it was not documented, it never happened!

14. HIPAA

15. HIPAA • HIPAA stands for “Health Insurance Portability and Accountability Act.” • HIPAA was first passed by Congress in 1996 to protect individuals whose medical information was being sent electronically. • On April 14, 2003, the Privacy Rule took effect, requiring all parties, who are communicating about a patient, to take steps to ensure confidentiality. • The Privacy Rule also covers notifying individuals of the use of their PHI (Personal Health Information). • HIPAA also allows patients to view their own medical records, correct any misinformation, and be informed how medical information is shared.

16. Importance of Privacy • Throughout our nation’s history, we have placed the rights of the individual at the forefront of our democracy. In the Decoration of Independence, we assured the “inalienable right” to “life, liberty and the pursuit of happiness.” many of the most basic protections in the Constitution of the United States are imbued with an attempt to protect individual privacy while balancing it against the larger social purposes of the nation. http://ba.hipaaps.com/privacy.html

17. Does the HIPAA Privacy Rule permit doctors, nurses, and other health care providers to share patient health information for treatment purposes without the patient’s authorization? • Yes. The Privacy Rule allows those doctors, nurses, hospitals, laboratory technicians, and other health care providers that are covered entities to use or disclose protected health information, such as X-rays, laboratory and pathology reports, diagnoses, and other medical information for treatment purposes without the patient’s authorization. This includes sharing the information to consult with other providers, including providers who are not covered entities, to treat a different patient, or to refer the patient.

18. Individual Plans (IP) and Behavioral Plans (BP) • Behavior Plans are located in the front left pocket of a client’s file. • Behavior Plans are formed by a team that targets unwanted behavioral issues; the goal of the plan is to reduce the number of unwanted behaviors. Behavior Plans are reviewed annually. • The first two pages of the Individual Plan consists of basic information about the participant, including name, phone number, date of birth, social security number, diagnoses, medical insurance numbers, primary care physician, etc. • The IP also consists of the client’s social history, needs and abilities, summary of achievements since the previous IP was completed, preferences, and goals.

19. Let’s Test Your Knowledge • Print the quiz at the end of this presentation and answer the questions • Submit your quiz to Mary Tennison • You must pass the quiz or you will need to repeat the class

20. Quiz- Emergencies and Documentation Name: _________________________ Date: ________________ Fill in the blank. “If it was not documented, it never __________________________.” Direct Care staff is responsible for reading Behavior Plans. True_____ False_____ Your documentation can be used in court. True_____ False_____ For legal purposes, what color ink should be used? _________________________ You may use white-out on documents. True_____ False_____ What should you do to better prepare yourself in an emergency situation? __________________________________________________________________________________________________________________________________________________________________________________________________ At TCLE, who do you contact in the event of an emergency? _________________________________________ If you are in an automobile accident while driving an agency vehicle, who should you contact at TCLE? __________________________________ Where are the registration and insurance card located in an agency vehicle?______________________________ HIPAA was formed to protect what? ______________________________