DOCUMENTATION

If It Isn’t Written, It Wasn’t Done!

If It Wasn’t Done, Don’t Write It!

Are You Going To Remember the Incident, Let Alone the Details, In 10 Years?

OVERVIEW

• Components & Procedures of the Written Report
• Legal Aspects & Benefits of Documentation
• Documentation Concerns in Patient Refusals

PREHOSPITAL CARE REPORT

Functions of the Trip Sheet (PCR)

• Continuity of Care

• Tracks Trends and Changes

• Legal Document

• Permanent Patient Record

• Protected By HIPPA

• Court Ordered Subpoena
• Confidential !!!

• Education
• Unusual Cases
• Administrative
• Billing & Statistics
• Research
• State & Federal Agencies
• Quality Improvement
• Trip Sheet
• Hand Written
• Computerized
• EMMA
• EMS Charts
• PDA’s

HIPAA

• Health Insurance Portability and Accountability Act of 1996
• http://www.cms.hhs.gov/hipaa/
• Very Complicated Law
• Its Most Simple Explanation
• Confidentiality
• Protect Records
• Don’t Tell Anyone Anything

PREHOSPITAL CARE REPORT

• Parts of the PCR
• Administrative
• Call Information
• Run Data
• Patient Personal Information
• Patient Care Information
• Patient Data
• Narrative

DOCUMENTATION

• Starts At The Time Of Call
• Dispatch Information
• Information Given While Enroute
• Scene Information
• "Upon Arrival Found…"

DOCUMENTATION

• Patient
• Age, Sex, Race
• Where
• Level Of Consciousness
• AVPU
• Chief Complaint
• General Impression, Initial Assessment
• OPQRST, SAMPLE

DOCUMENTATION

• Patient (continued)
• Examination
• Vital Signs – Baseline & Reassessed
• Skin, Lungs, Pupils, Glasgow Coma Score, Capillary Refill
• Treatment Given
• How Was the Patient Extricated or Moved
• Did the Patient Get Better/Worse

DOCUMENTATION

• Were There Complications
• Document Patient Quotes
• Patient Stated, "Yadda, Yadda, Yadda…"
• Was Medical Command Contacted
• What Orders Were Received?
• Record Times
• Record Who Did What

DOCUMENTATION

• You Are the Artist
• Paint the Picture
• Don’t Whitewash the Wall
• Details Details Details
• Recall Years Later

TIME

• Call Received
• Call Acknowledged
• Unit Enroute
• On Scene
• Arrive at Patient
• Transport to Hospital
• Arrive at Hospital
• Back in Service
• Back in Quarters

TIME

• Synchronize Clocks and Watches
• Record Time for Every Treatment Listed
• Essential Equipment of the EMT =

PREHOSPITAL CARE REPORT

• Items Not Already Discussed
• Spelling or Should I Say

• Look It Up or Ask
• Carry Small Medical Dictionary

PREHOSPITAL CARE REPORT

• Do Not Use Business For Street Address
• Businesses Close
• Avoid Radio Codes
• Code 48 : Possible Over Dose
• Write Legibly
• Use Medical Terminology Correctly
• Be Observant

PREHOSPITAL CARE REPORT

• Include Objective Information
• Observable, Measurable, Verifiable
• The Patient Has A Laceration…
• Subjective Information
• Individuals Point of View
• I Am Dizzy
• The Patient Appears to Be...

PREHOSPITAL CARE REPORT

• Ovoid Opinions
• Don’t Go Beyond Your Realm of Training
• I Don’t Think the Patient’s Arm is Broken
• Ovoid Irrelevant Statements
• Something That Does Not Deal With Patient Care
• The Patient Has Ugly Children

PREHOSPITAL CARE REPORT

• Use Quotations
• Identify the Speaker
• The Patient Stated "My Chest Hurts"
• The Patient’s Wife Stated "He Had 3 Seizures Today"
• Include Pertinent Negatives
• Items That Did Not Happen or Not Occurring
• The Patient Denies L.O.C.
• Patient Reports He Is Not S.O.B.

PREHOSPITAL CARE REPORT

• Falsification
• DO NOT LIE
• If Error or Omission Occurs
• Document What Did or Did Not Happen and What Steps Were Taken to Correct

PREHOSPITAL CARE REPORT

• Suspension
• Revocation
• Proof of Poor Patient Care
• Dangerous Assumptions May Be Made About Further Patient Care
• Areas of Tempt
• Vitals – Made Up
• Treatment – Made Up or Omitted

PREHOSPITAL CARE REPORT

• Errors While Writing / Generating
• Draw Single Horizontal Line
• Indicate Error
• Initial
• Write Correct Information

• Do Not Obliterate – Looks Like Cover-Up
• Scribbling
• "White Out" – Big No No’s

PREHOSPITAL CARE REPORT

• Error Discovered After Completion / Submitted
• Different Color Ink
• Draw Single Line
• Indicate Error
• Initial and DATE
• Write Correct Information

• If Information Was Originally Omitted
• Write Information
• Sign & DATE

PATIENT REFUSALS

• Competent Adults Are Allowed to Refuse
• Ensure Patient is Able to Make Rational Decision
• Under the Influence - Not Rational
• Drugs, Alcohol, Illness/Injury
• Try to Persuade Patient to Transport
• Inform Patient of Potential Dangers
• Inform Patient of Benefits of Transport

PATIENT REFUSALS

• Consult Medical Command When Needed
• Offer Alternatives if Possible
• If Needed You Will Return
• Seek Medical Attention, PCP or E.D.
• Patient Should Sign Refusal
• Have Witness Sign
• Now Document Everything

DOCUMENTING
MASS CASUALTY INCIDENT

• Complete Report Later
• Keep Notes
• Important Points
• Multi-Copy Forms
• Triage Tags & Numbers
• Local EMS Have Policies Dealing w/ MCI

SPECIAL SITUATION REPORTS

• Abuse
• Area Agency of Aging
• Children & Youth Services
• Injury to Yourself
• Work Comp Forms
• Exposure
• Work Comp
• Others ?
• Departmental Incident Reports