Documentation Auditing Clinic PCR Examples

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1 Program Materials Documentation Auditing Clinic PCR Examples Day Two Copyright , PWW Media, Inc. All Rights Reserved. All Use Subject to Attendee License Agreement.

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3 RUN NUMBER: 2014T001 PATIENT NAME: Faulfrohm, Grace DATE OF SERVICE: 12/3/2014 CALL RECV D 12:05:34 DISPATCH CODE 004-Fall TO SCENE 0.0 DISPATCH 12:07:55 RESPONSE Bravo ON SCENE 0.0 ENROUTE 12:08:42 LOCATION 12 Main St (Arby s) ENROUTE TO DEST. 0.0 ON SCENE 12:11:26 ED TO Medical Center AT DEST. 6.8 DEPART SCENE 12:31:14 Bravo MILEAGE 6.8 ARRIVE DEST. 12:45:33 DISPATCH COMMENTS: Fall from moving vehicle at drive thru NAME Grace Faulfrohm DOB 12/16/42 AGE 71 WEIGHT 178 ADDRESS 58 Potter Circle SEX F COMPLAINT None PT FOUND On ground MEDICAL HX Hypertension MEDICATIONS Multiple ALLERGIES NKDA IMPRESSION Trauma Airway: Clear; Breathing: Normal; Circulation: Normal; CRT: 2 seconds or less; Skin: Normal; Neuro AVPU: Alert Orientation x4, moves all extremities; Neuro Sensory: Intact; Speech: Intact; Eyes: PERRL GCS: Motor: 6; Verbal: 5; Eye: 4; Total: 15. Injury: Onset- Provocation-Quality-Radiation-Severity-Time Type of activity: Leisure; Location: Street/Highway; Intent: Unintentional; MOI: MVC : Pt. fell out of moving vehicle. Abrasions to ankles, hands and face. Pt. complains of left hip pain. Pt. stated she was ordering chicken and opened the door since the window did not work. She accidentally stepped on gas pedal and fell out of the truck onto a hard surface. Pt. was A&O x4, BSCBL, MAEW, No LOC. T. found lying on ground. EMS log rolled pt. onto the backboard after placing C- Collar. After moving pt. she was still able to MAEW. Pt. transported to Hospital for further evaluation. 12:15:19 Spinal immobilization Collar/Backboard 12:17:20 144/ % See above 12:27:54 IV RAC; 18 G NSS (100) TKO 12:40:21 144/ % NAME CERT# LEVEL SIGNATURE NAME CERT# LEVEL SIGNATURE

4 RUN NUMBER: P PATIENT NAME: Leeve, Mae B. DATE OF SERVICE: 7/3/14 CALL RECV D DISPATCH CODE Psych TO SCENE DISPATCH RESPONSE Alpha ON SCENE ENROUTE 19:46 LOCATION Good Samaritan Hospital ENROUTE TO DEST. 0.0 ON SCENE 20:20 ED TO General Hospital AT DEST DEPART SCENE 20:39 Alpha MILEAGE 27.7 ARRIVE DEST. 21:20 DISPATCH COMMENTS: Suicide attempt - Mental/Psych interfacility transfer NAME Mae B. Leeve DOB 7/1/1946 AGE 68 WEIGHT 105 ADDRESS SEX F COMPLAINT Suicidal ideation PT FOUND Seated on floor MEDICAL HX Alcohol abuse MEDICATIONS UNK ALLERGIES PCN IMPRESSION None entered Dispatched to above location for combative female in psych hold. Upon arrival in patient s room. Pt. was screaming and yelling she was refusing to go, sitting in corner of room knees to face, clutching what appeared to be a small stuffed animal. After I spoke with the patient for a few minutes, she agreed to be transported on our stretcher, without being restrained. Pt. just secured with basic cot straps. Pt. had bandages to wrists. During transport, pt. assessment was performed, and vitals (x2) were taken. About 15 minutes into transport, pt. fell asleep and remained asleep until we arrived at our destination. Assessment: Airway: Patent; Breathing: Normal; Circulation: CAP refill < 2 sec; Blood loss: None noted; Skin: Intact; Mental status: Combative; Neurological: Normal Cause of Injury: Not available; MOI: Not available; Injury intent Type: Not known 20:31 Moved to stretcher 20:46 142/ GCS = 15; Eyes: PERRL 20:46 140/ Skin: Warm, dry, pink; Lungs: Clear NAME Peter Pan CERT# LEVEL SIGNATURE NAME Tinker Bell CERT# LEVEL SIGNATURE

5 RUN NUMBER: S PATIENT NAME: Burns, Redd DATE OF SERVICE: 5/24/15 CALL RECV D 16:10:21 DISPATCH CODE Burns TO SCENE DISPATCH 16:40:14 RESPONSE Charlie ON SCENE ENROUTE 14:40:24 LOCATION General Hospital ENROUTE TO DEST. 0.0 ON SCENE 16:44:39 ED TO Medical Center AT DEST. 8.7 DEPART SCENE 17:17:16 Charlie MILEAGE 8.7 ARRIVE DEST. 17:29:38 DISPATCH COMMENTS: Sick Person NAME Redd Burns DOB 2/8/1946 AGE 69 WEIGHT 210 ADDRESS 18 Pioneer Lane SEX M COMPLAINT General Illness Burns- pulseless limb PT FOUND In Bed MEDICAL HX Hypertension; Hyperlipidemia; A-Fib MEDICATIONS Aendronate; Ascorbic Acid; Metoprolol; Rosuvastin ALLERGIES NKA IMPRESSION Burn pulseless limb Unit 1-5 Dispatched Code 3 to General Hospital for 79 yom. Pt. was in CT scan caused delay in transport. RN states pt. CC pain in right calf and foot = with no pulse in right leg. Pt has burns to chest, legs and arms. Pt. has heparin running at 12.6ml/HR. Pt. also received 2.6 mg Metropolol at 17:15. Pt. has chronic history of controlled A-fib. Pt. being transported to Medical Center for surgery related to burns. Upon arrival pt. found lying semi-fowlers. Pt. is A&O x4, with GCS of 15. Pt. sheet lifted to stretcher x 5 straps. HEEMT: Clear of fluid; Mucous membrane: Pink & moist; Pupils: PERRL; Neck: Supple; R-foot: Pulse unpalpable, other extremities normal. PT sheeted to bed at destination. Pt. care paperwork handed to RN without incident. 17:04 165/ % 98.6 GCS=15; Eyes: PERRL; A&Ox4 17:09 162/ % Skin: Normal/Pink Cap refill: Normal 17:15 166/ % GCS=15; EKG: A-fib NAME Happy Dwarf CERT# P LEVEL P SIGNATURE Happy Dwarf NAME Dopey Dwarf CERT# B LEVEL B SIGNATURE Dopey Dwarf

6 RUN NUMBER: NE PATIENT NAME: Reen, Al DATE OF SERVICE: 12/3/ : :42 (8/2/11) CALL RECV D DISPATCH CODE 033- Transfer TO SCENE DISPATCH 05:10 (12/3/11) RESPONSE Alpha - Pre-Scheduled ON SCENE ENROUTE 05:10 LOCATION Residence ENROUTE TO DEST ON SCENE 05:20 ED TO Dialysis Center AT DEST DEPART SCENE 05:37 Alpha - Transfer MILEAGE 15.3 ARRIVE DEST. 05:45 DISPATCH COMMENTS: Routine Dialysis NAME Al Reen DOB 4/15/41 AGE 74 WEIGHT 0 lbs ADDRESS 18 Mockingbird Lane SEX M COMPLAINT Going for dialysis PT FOUND MEDICAL HX Gout, Dementia, Hyperlipidemia MEDICATIONS ALLERGIES UNK IMPRESSION Renal Failure: Chronic Assessment: Airway: Patent; Breathing: Normal; Circulation: Cap. Refill: < 3 seconds; LOC: Dementia Dispatched to above location to transport a 70 yom going to Dialysis Center for dialysis treatment. On scene, found pt. lying in bed, C&A, just finished eating breakfast. Family present noted that pt. just developed a large bump on his L AC near infusion site. Pt. moved to stretcher. Monitored during transport, pt. stable, did not want vitals taken. Resting, no complaints, uneventful trip. ETCO2 TEMP See above. None NAME Flounder Ing CERT# B LEVEL B SIGNATURE Flounder Ing NAME Hans Southern CERT# B LEVEL B SIGNATURE

7 RUN NUMBER: B PATIENT NAME: Seep, A.P. DATE OF SERVICE: 3/4/15 09:52 CALL RECV D DISPATCH CODE 002- Respiratory TO SCENE DISPATCH 09:54 RESPONSE Delta ON SCENE ENROUTE 09:58 LOCATION Residence ENROUTE TO DEST. ON SCENE 10:20 ED TO Holy Spirit Hospital AT DEST. DEPART SCENE 10:33 Delta MILEAGE ARRIVE DEST. 10:59 DISPATCH COMMENTS: SOB NAME A.P. Seep DOB 10/3/1955 AGE 70 WEIGHT 175 ADDRESS 1090 Fir Street SEX M COMPLAINT PT FOUND MEDICAL HX ALLERGIES MEDICATIONS IMPRESSION Dispatched by County 911 dispatch to incident report for male patient with SOB. Responded Priority 1 from station. Also dispatched with BLS unit. AOS to find pt. lying Semi-Fowlers on BLS stretcher, in care of BLS crew. According to Pt. he has been SOB for the past couple of days. He stated that it eases when he sits down or rests, but gets worse on exertion. Pt. denies any chest pain or other complications. Pt. states he has COPD. Assessment: Pt is CA&Ox4. He is breathing 20 times / minute non-labored, using complete sentences to talk, no JVD, trachea is midline and lungs have exp. Wheezing. No signs of trauma and stroke assessment is unremarkable. Treatment: ALS assessment performed. Vitals taken and reassessed (see below). EKG shows sinus tachycardia. Pt. placed on O2 at 2 lpm via NC. Nebulized albuterol given and pt. reports no changes. IV access unsuccessful. Upon arrival, pt. condition was unchanged. Pt. transported by BLS unit for SOB. 10:21 Left & Right Lung: Wheezing 10:23 142/ % 99.2F Perfusion: Normal 10:24 GCS=15 EKG: ST; IV LAC 20 G; NSS TKO 10:29 Albuterol 2.5mg via inhalation 10: % GCS=15 NAME Donald Duck CERT# P LEVEL P SIGNATURE Donald Duck NAME Daisy Duck CERT# B LEVEL B SIGNATURE Daisy Duck