Transcript 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 patient’s 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 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
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; 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
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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