Chapter 1

Chapter 1

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. 2. Define key terms introduced in this chapter. Describe each of the following purposes served by the

prehospital care report (PCR) (slides 12-22): a. b. c. d. e.

3. Continuity of patient care Administrative uses Legal document Education and research Evaluation and continuous quality improvement (CQI)

Describe characteristics, including advantages and disadvantages, of both paper and computer-based (electronic) PCR formats (slides 23-24). Objectives 4.

5. 6. Explain the purposes of the U.S. Department of Transportation (DOT) minimum data set for PCRs ( slide 26).

List the elements of the DOT minimum data set for PCRs (slides 26-27). Describe the purpose and contents of each of the following sections of a PCR (slides 28-37): a. b. c.

d. e. Administrative data Patient demographics and other patient data Vital signs Narrative

Treatment Objectives 7. Give examples of each of the following types of PCR narrative information (slides 34-35): a. b.

c. d. e. Chief complaint Pertinent history Subjective information Objective information

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. b. c. d.

e. Confidentiality Allowed distribution of the PCR or information included in it Documenting a patients refusal of treatment Falsification of the PCR 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).

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 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 didnt have enough trouble today, Ive got to deal with you guys! Go away. I dont need any help! How would you proceed?

Functions of the Prehospital Care Report Back to Topics

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 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 Educational and Resource

Uses Can look at positive or negative effects May identify training needs Evaluation and Continuous Quality Improvement

Documentation part of quality improvement Medical oversight Collection of Data in Prehospital Care Reports

Back to Topics PCR Formats Back to Objectives

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

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

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.

PCR Data Patient Narrative Back to Objectives Chief complaint

SAMPLE Objective data Subjective data Pertinent negatives

PCR Data Treatment Treatment Time Effect on patient

status Legal Concerns Back to Topics Confidentiality

Back to Objectives 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 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 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 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 Multiple-Casualty Incidents

Follow local MCI plan for record keeping Use triage tags ( Stephanie Ruet/Corbis Sygma) Special Reports

( David Handschuh)

Suspected abuse Exposures Injuries to EMS members Information for other agencies Alternative

Documentation Methods Back to Topics SOAP

Back to Objectives

S Subjective O Objective A Assessment P Plan CHART

C Chief complaint H History

A Assessment R Rx T Transport CHEATED

C Chief complaint H History E Exam A Assessment T Treatment E Evaluation D Disposition

Medical Abbreviations Back to Topics 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 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 SpO2 is 96 percent on room air Critical Thinking Scenario SAMPLE history:

S Feels light-headed and dizzy every time she stands up; shes 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 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 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? 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

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