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Documentation

This documentation provides a record of scene information, ensures continuity of patient care, serves as medical-legal evidence, and aids in statistics, budgeting, quality assurance, and education. It discusses different types of patient care reports, including traditional written reports and computer-based systems. The elements of a patient care report and guidelines for documenting patient information, narratives, and other essential items are explained. The SOAP method, correcting mistakes, and the importance of accurate documentation are also discussed.

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Documentation

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  1. Documentation EMT 170 Emergency Communications and Patient Transportation (Cars & Radios)

  2. Documentation – Purpose • Provides a record of scene information that may not be available from any other source • Provides information for the continuity of patient care from one healthcare provider to another • Provides a record of specific pre-hospital interventions performed or attempted • Provides medical legal evidence • Reveals any significant changes in the patient’s condition • Provides an internal tool for statistics, budgeting, QA and education

  3. Patient Care Report – Types of Reports • Traditional written report • Typically provides check boxes and a narrative section • EMT completes it in written form • Computer-based report • Generated on an electronic clipboard or mobile data terminal • EMT enters information by special instrument or keyboard

  4. Written Patient Care Report(PCR)

  5. Written Patient Care Report(PCR)

  6. Computer Based Report System

  7. PCR-Report Elements • Run data • Patient data • Narrative information

  8. Run Data • Service name • Unit number • Crew license numbers and/or names • Location of call • Response times mileage

  9. Patient’s name Age Location of patient Pupillary response Assessment Address Sex LOC Vital signs Care provided Patient Data • DOB • MOI/NOI • Sensation • PMH • Response to treatment

  10. Narrative • Used to document • Patient complaint/history • Observation • Physical assessment finding • Care delivered by EMS crew • Changes in patient condition • SOAP

  11. General Guidelines • Collect all patient information • Complete all blanks and check all pertinent boxes on call report form • Do not leave any spaces blank, mark “N/A” if item does not apply • Begin narrative by documenting the patient's LOC

  12. General Guidelines (cont.) • Attach EKG documentation (where applicable) with date, time and patient's name on it • Sign the report • Leave a copy of the report with the patient’s chart

  13. Items to Document • Patient’s chief complaint using patient’s own words within quotation marks if possible • History of present illness or injury using OPQRST format • Physical assessment findings including pertinent positives and pertinent negatives • Significant pertinent past medical history including surgeries, hospitalizations, illnesses or injuries

  14. Items to Document (cont.) • Allergies and current medications • Interventions, who performed them, time performed, and the patient’s response or lack of response to interventions • Vital signs and times obtained

  15. Writing a Narrative • Use plain language and medical terminology • Avoid slang • Use only recognized abbreviations • Spelling general neatness are imperative to convey professionalism

  16. SOAP Method S – subjective • Information the patient tells you • Patient symptoms O – objective • Information the EMT observes about the scene and possible injuries A – assessment • EMTs evaluation of the situation, the patient’s chief complaint and findings based on the exam P – plan • The plan of action and care delivered the EMT

  17. Other Narrative Forms • Head-to-toe format • Chronological format

  18. Correcting Mistakes • Do not erase or mark out a mistake • Draw a single line through the error and place initials beside the line • Add the correct information following the correction • If information was initially omitted, add a note with additional information, the date, and the EMTs initials

  19. Errors • DO NOT attempt to cover mistake • Document what did or did not happen and what corrective action (if any) was taken • Falsifying information on a PCR is harmful to the patient and may lead to the suspension or revocation of the EMTs certification and other legal action

  20. Summary • Documentation is the most important non-clinical skill possessed by the EMT • The patient care report must be accurate and report both subjective and objective findings, physical assessment results, care and treatment rendered and any significant observation of the scene • The PCR is considered a legal document that serves as an official record of care given • The PCR is the EMTs first line of defense if questions are later raised about the incident

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