Chapter 4 Documentation Prehospital Emergency Care, Ninth Edition Joseph J. Mistovich Keith J. Karren Copyright 2010 by Pearson Education, Inc. All rights reserved. Objectives 1. Define key terms introduced in this chapter. 2. Describe each of the following purposes served by the prehospital care report (PCR) (slides 12-22): a. Continuity of patient care b. Administrative uses c. Legal document d. Education and research e. Evaluation and continuous quality improvement (CQI) 3. Describe characteristics, including advantages and disadvantages, of both paper and computer-based (electronic) PCR formats (slides 23-24). Objectives 4. Explain the purposes of the U.S. Department of Transportation (DOT) minimum data set for PCRs (slide 26). 5. List the elements of the DOT minimum data set for PCRs (slides 26-27). 6. Describe the purpose and contents of each of the following sections of a PCR (slides 28-37): a. Administrative data b. Patient demographics and other patient data c. Vital signs d. Narrative e. Treatment 1
Objectives 7. Give examples of each of the following types of PCR narrative information (slides 34-35): a. Chief complaint b. Pertinent history c. Subjective information d. Objective information e. Pertinent negatives 8. Use common abbreviations and medical terminology accurately in PCRs (slides 63-64). Objectives 9. Explain each of the following legal concerns with respect to the PCR (slides 38-48): a. Confidentiality b. Allowed distribution of the PCR or information included in it c. Documenting a patient s refusal of treatment d. Falsification of the PCR e. Correction of errors Objectives 10. Discuss how to handle each of the following situations with respect to the PCR (slides 48-55): a. Transfer of patient care when returning to service prior to completing the PCR b. Multiple-casualty incidents (MCIs) c. Special reporting situations, such as infectious disease exposure and suspicion of abuse or neglect 11. Accurately and completely record pertinent patient and EMS call information using the SOAP, CHART, and CHEATED methods (slides 56-62). 2
Topics Functions of the Prehospital Care Report Collection of Data in Prehospital Care Reports Legal Concerns Special Situations Alternative Documentation Methods Medical Abbreviations CASE STUDY Dispatch EMS Unit 17 Respond to 57 Vallejo Road for a vehicle versus a parked car Time out 1321 3
Upon Arrival Female party who called 911 indicates the male who struck her vehicle was slumped over wheel States now he seems okay As you approach a mid-30s male he states, Great! As if I didn t have enough trouble today, I ve got to deal with you guys! Go away. I don t need any help! How would you proceed? Functions of the Prehospital Care Report Back to Topics 4
Continuity of Medical Care Back to Objectives Provides a baseline for other providers Gives an understanding of events and reasons for the call Administrative Uses 5
Becomes part of patient record Used for billing Statistics Legal Document Is legal document May appear as a witness Can be months or years later May be a defense 6
Educational and Resource Uses Can look at positive or negative effects May identify training needs Evaluation and Continuous Quality Improvement 7
Documentation part of quality improvement Medical oversight Collection of Data in Prehospital Care Reports Back to Topics PCR Formats Back to Objectives 8
Written Computerized PCR Data The Minimum Data Set Back to Objectives Chief complaint Level of responsiveness Blood pressure Skin color, temperature, and condition Pulse rate Respiratory rate and effort Patient demographics Times of the call 9
PCR Data Administrative Information Back to Objectives EMS unit and run or call number Names of crew and levels of certification Address to which unit is dispatched PCR Data Patient Demographics and Other Patient Data 10
Legal name, age, sex, race, and birth date Home address Location where you found the patient Insurance/billing Care rendered prior to EMT arrival PCR Data Vital Signs At least two sets should be taken prior to arrival. 11
PCR Data Patient Narrative Back to Objectives Chief complaint SAMPLE Objective data Subjective data Pertinent negatives PCR Data Treatment 12
Treatment Time Effect on patient status Legal Concerns Back to Topics Confidentiality Back to Objectives 13
Information on PCR is confidential Be familiar with HIPAA Distribution ( Ray Kemp/911 Imaging) Follow state rules and local protocol for PCR distribution Leave a copy of PCR at receiving facility 14
Refusal of Treatment Document competency Document your efforts completely Have patient sign refusal Offer patient alternate methods of getting care Remind patient that EMS can always return Falsification 15
Do not try to cover up mistakes Do not compromise patient care Falsification Correcting Errors Draw single line, initial it, write the correct information beside it Do not erase Do not write over Back to Objectives 16
Special Situations Back to Topics Transfer of Care Report Obtain a signature from the medical professional who is assuming care Leave a copy of report with facility 17
Multiple-Casualty Incidents Follow local MCI plan for record keeping Use triage tags ( Stephanie Ruet/Corbis Sygma) Special Reports 18
( David Handschuh) Suspected abuse Exposures Injuries to EMS members Information for other agencies Alternative Documentation Methods Back to Topics SOAP Back to Objectives 19
S Subjective O Objective A Assessment P Plan CHART C Chief complaint H History A Assessment R Rx T Transport 20
CHEATED C Chief complaint H History E Exam A Assessment T Treatment E Evaluation D Disposition Medical Abbreviations Back to Topics 21
Examples: BP Blood pressure bpm beats per minute CVA Cerebrovascular accident CHF Congestive heart failure Only use universally accepted medical abbreviations. Back to Objectives CASE STUDY Follow-Up CASE STUDY Assessment You notice he has a bruise above left eye You are able to calm patient He refuses all assessment and treatment 22
CASE STUDY Documentation You note all pertinent findings Document refusal Have Mr. Makynen read and sign refusal Suggest Mr. Makynen see a doctor or call 911 if things change Now clear and in service Critical Thinking Scenario 36-year-old female complaining of severe abdominal pain The patient is alert and oriented Vital signs: BP: 88/64 mmhg HR: 128 bpm with weak radial pulses RR: 24 with adequate chest rise Skin is pale, cool, and clammy SpO 2 is 96 percent on room air Critical Thinking Scenario SAMPLE history: S Feels light-headed and dizzy every time she stands up; she s also nauseated A No known allergies M Over-the-counter Claritin for allergies P No pertinent medical history; tonsils removed when she was ten years old L Nothing to eat or drink for seven hours E Has not felt real good for a few days 23
Critical Thinking Scenario Pain assessment: O Pain began suddenly and has progressively worsened; was sitting on the couch watching television when it began P Nothing makes it better or worse Q Dull, aching, and intermittent R Nonradiating S Eight out of ten T Four hours Critical Thinking Scenario Physical exam: Pupils are equal and sluggish to respond Breath sounds are equal and clear bilaterally; no JVD Abdomen is rigid and tender; no evidence of trauma to the abdomen Good motor and sensory function in all four extremities; peripheral pulses are very weak Critical Thinking Scenario Repeat vital signs: BP: 82/62 mmhg HR: 134 bpm, radial pulses barely palpable RR: 26 with adequate chest rise Skin is more pale, cool, and clammy Pulse oximeter reading error 24
Critical Thinking Scenario En route to the hospital, the patient begins to close her eyes You must verbally instruct her to open her eyes For your PCR documentation: Jennifer Sampson 1321 Oakridge Drive Smithville, Ohio Critical Thinking Questions 1. What can this information be used for? 2. How will the medical personnel in the medical facility use the information? 3. What will your EMS use the information for? 4. What would you document in the patient information section of the minimum data set? Critical Thinking Questions 5. What would you document in the administrative section of the PCR? 6. What information would you write in the patient narrative section? 7. Should any of the information not be reported in the PCR? 8. If you were to make a mistake while writing the PCR, how would you correct it? 25
Critical Thinking Questions 9. If the PCR contains a box for a third set of vital signs, what would you document in this patient? 10.How would you collect additional information needed for your PCR? Reinforce and Review Please visit www.bradybooks.com and follow the mybradykit links to access content for the text. 26