Transcript Pre-Hospital Documentation Vermont Emergency Medical Services The Vermont Department of Health

The Vermont Department of Health
Pre-Hospital Documentation
Vermont Emergency Medical Services
Last updated October 2006
The Vermont Department of Health
An Actual Run Form
Upon our arrival, found pt in bed with first responders complaining of
breathing difficulty. Pt. physician saw her yesterday. Had cold X 2 weeks.
Physician said lungs were congested. Nauseated, no vomiting. Upon listening
to lung, equal but noisy. Pt initially put on 4 liters nonrebreather, complained
so we used 24% Venturi.
Allergic codeine. Dr. Bitlett. Pt diabetic due for insulin 8:00. Meds insulin.
The Vermont Department of Health
An Actual Run Form
Upon our arrival, found pt in bed with first responders complaining of
breathing difficulty. Pt. physician saw her yesterday. Had cold X 2 weeks.
Physician said lungs were congested. Nauseated, no vomiting. Upon listening
to lung, equal but noisy. Pt initially put on 4 liters nonrebreather, complained
so we used 24% Venturi.
Allergic codeine. Dr. Bitlett. Pt diabetic due for insulin 8:00. Meds insulin.
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Session Goal
 At the end of this session, the student will be
able to use the Vermont EMS Incident Report
Form to document a pre-hospital call in a
systematic and complete fashion.
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Learning Objectives
At the end of this session, the student will be able to:
1. describe the SOAP or CHART method of charting
2. list at two principles of writing a narrative
3. describe the role of documentation when a patient refuses
care or transport
4. describe how care administered to a patient in a multiple
casualty incident is documented
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Learning Objectives
5. given pieces of information (in random order) about a call, properly
document the assessment and treatment of the patient
6. describe the procedure to use when adding or correcting information on
the run report form after the copies have been separated
7. (for Advanced EMTs only) list the pieces of information which should be
recorded on the run report form when the EMT administers advanced
life support in the field.
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What This Session Will Cover
 Importance & Purposes of Documentation
 Frequent Problems (and Solutions)
 Completing the VT EMS Incident Report Form
 Exceptions and Special Cases
 Demonstration and Practice
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Purposes of Documentation
 educational
• properly done within HIPAA
requirements
 administrative
• statistics and billing
 research
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Purposes of Documentation
 evaluation and critique
• What proportion of patients with a
chief complaint of difficulty breathing
receive high concentration oxygen?
 continuity of treatment in hospital
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Purposes of Documentation
 legal
• form is not evidence in itself
• becomes evidence as part of testimony of
witness to authenticate it
• can be used to refresh the memory of a
witness
• retain original for legal purposes
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Kinds of Errors
 incomplete or incorrect blanks and boxes
(e.g., date)
SOLUTION?
have someone else check the form
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Kinds of Errors
 incomplete or incorrect narrative (e.g.,
description of a patient's injuries without
mentioning that he was in a collision
SOLUTION?
use an outline to remind yourself what information
to include
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Kinds of Errors
 form reflects incomplete assessment or poor care
SOLUTION?
document extenuating circumstances





combative patient
language barrier
pt refusal to cooperate
extrication difficulties
delay in response, at the scene, or en route to ED
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Kinds of Errors
 form reflects incomplete assessment or poor
care
SOLUTION?
if deviation from the usual treatment protocols
occurred, explain why; do not try to cover up
errors or omissions in care
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The Vermont EMS
Incident Report Form
or Patient Care Report
(PCR)
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PCR Demographic Info
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Code 2/Code 3
 Any use of lights OR siren = Code 3
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Nature of Call/CC
 Fill in the chief complaint or nature of call as
found, not as dispatched
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Treatment & Vital Signs
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Level of Treatment & Transport
 Fill in treatment based
on what the agency
completing the form did
for the pt
 Fill in transport based on
treatment the pt is
receiving, regardless of
who gives it
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Trauma Score
 Complete for trauma patients
only
 Use information from earliest
EMS assessment
 Let the hospital worry about
adding up the numbers
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Vital Signs
 Repeat VS frequently
 Put SpO2, blood glucose, etc. in comments
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Vital Signs
 As needed, draw lines to make additional
boxes for vital signs
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A System for Comments
S
O
A
P
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The SOAP System
Subjective
Objective
Assessment
Plan
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Another System for Comments
C
H
A
R
T
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The CHART System
Chief complaint
History
Assessment
Rx (treatment)
Transport
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SOAP
 Subjective
• Chief Complaint (CC)
• History of Present Illness (HPI)
• Past Medical History (PMH)
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Subjective/History
 History of Present Illness (HPI)
•
•
•
•
•
•
•
O
P
Q
R
S
T
U
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Subjective/History
 History of Present Illness (HPI)
• Onset
• Provokes
• Quality/Quantity
• Region/Radiates
• Severity
• Time
• Undo
+ associated symptoms
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Subjective/History
 Past Medical History (PMH)
•
•
•
•
•
M
A
I
D
S
A
M
P
L
E
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Subjective/History
 Past Medical History (PMH)
•
•
•
•
•
Medications
Allergies
Illnesses
Doctor
Surgery
Allergies
Medications
Pertinent past history
Last oral intake
Events leading to illness
or injury
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Objective/Assessment –
Trauma






pt appearance, position and surroundings
head, eyes, ears, nose, throat
neck
chest
abdomen and pelvis
extremities
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Objective/Assessment - Cardiorespiratory





pt appearance, position and surroundings
neck – jugular veins
chest – lung sounds
extremities – pedal edema
other – oxygen saturation, EKG as
appropriate
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Objective/Assessment –
Altered Mental Status
 pt appearance, position and surroundings
 mental status
•
•
•
•
AVPU
orientation
memory
loss of consciousness
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Objective/Assessment –
Altered Mental Status
 pupils
 trauma exam, including movement of
extremities
 other
• blood glucose
• oxygen saturation, EKG as appropriate
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Exercise #1
 In the first blank for each
phrase, indicate what kind
of information is given by
using Hx for history and
PE for physical exam.
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Principles of Narrative Comments
 Include pertinent negatives.
• If a pt c/o chest pain, document the presence or
absence of
.
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Principles of Narrative Comments
 Include pertinent negatives.
• If a pt c/o chest pain, document the presence or
absence of difficulty breathing.
The Vermont Department of Health
Principles of Narrative Comments
 Include pertinent negatives.
• If a pt c/o chest pain, document the presence or
absence of difficulty breathing.
• If a pt c/o a blow to the head, document whether
or not the pt
.
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Principles of Narrative Comments
 Include pertinent negatives.
• If a pt c/o chest pain, document the presence or
absence of difficulty breathing.
• If a pt c/o a blow to the head, document whether
or not the pt lost consciousness.
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Principles of Narrative Comments
 Describe, don’t conclude.
• “A well known, unshaved, unkempt, foul-smelling,
slightly cyanotic, 62 y/o alcoholic gentleman was
carried into our emergency room by three million
lice, all screaming, ‘Please save our host.’”
- from an actual doctor’s note shown to a
jury in a malpractice suit in 1977
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Principles of Narrative Comments
 Describe, don’t conclude.
• Pt had slurred speech, frequent mood swings
between happy and combative, inability to walk
without assistance and odor of alcoholic beverage
on his breath.
• Is there any need to say this pt was drunk?
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Principles of Narrative Comments
 Record important observations about the
scene.
• Suicide note found next to pt
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Principles of Narrative Comments
 Avoid radio codes on the form.
Code 11, 33, 55, 77
In the 1970s in some parts of Vermont, this meant:
Code 11 = emotional disturbance
Code 33 = overdose
Code 55 = alcohol intoxication
Code 77 = attempted suicide
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Principles of Narrative Comments
 Use only standard abbreviations.
• NOT, for instance
 CTD
(circling the drain)
 HIBGIA
(had it before, got it again)
 FTD
(fixing to die)
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Principles of Narrative Comments
 Include changes in the patient’s condition
after treatment or while en route.
• After 1 tube of oral glucose, pt became lucid and
thanked us profusely.
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Principles of Narrative Comments
 Identify the source of information when it is
not the patient.
• Per wife, pt has used cocaine for 2 years.
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Spelling
medication names
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Spelling
orient
X
orientate
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Spelling
clavicle
X
clavical
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Spelling
dilated
X
dialated
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Spelling
crepitus
X
crepidus
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Spelling
prostate
X
prostrate
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Spelling
palpitation
X
palpation
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Spelling
seize
seizure
(verb)
(noun)
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Spelling
diaphoretic
sweaty
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Punctuation
Who says punctuation
doesn’t count?
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Punctuation
Pt experiences difficulty swallowing tires easily.
OR
Pt experiences difficulty swallowing, tires easily.
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Punctuation
She moves her bowels roughly, three times a day.
OR
She moves her bowels roughly three times a day.
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Confidentiality
 Health Insurance Portability and
Accountability Act (HIPAA) Privacy Rule
• It’s not just the form that’s confidential, but the
medical information about the patient.
• HIPAA applies whenever your service bills a pt.
• Even if a pt doesn’t get a bill, the EMS agency and
providers are expected to maintain confidentiality.
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Exceptions and Special Cases
 Multiple Casualty Incidents
 Refusal of Care
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Multiple Casualty Incidents
 Use Met-Tags or
local approved
equivalent
 Standard of care
for documentation
is different in an
MCI
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MCI
In an MCI, fill out tag
as completely as
circumstances allow
Afterward, use tag to
complete PCR the
best you can
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Refusal of Care
 Vermont Supplemental
Report for Patient NonTransports
• to be used with nontransport protocol
• to be completed in
addition to PCR
• available free from EMS
Office
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Refusal of Care
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Refusal of Care
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Refusal of Care
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Refusal of Care
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Refusal of Care
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What About Other VT EMS Forms?
 VT EMS no longer collects
• Cardiac Arrest Report Forms or
• Esophageal Tracheal Combitube Forms
 Follow district medical advisor’s directions
 Both forms are available free of charge from
VT EMS Office
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Learning from Others’ Experience
 Evaluate the following narratives and
describe how they could be improved.
 Note: Information has been typed for ease of
reading, but these are actual forms.
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Example # 1
(20 y/o female)
Pt has not been feeling well X 1 day. At 4:00 am this date pt
started vomiting and uncontrollable bowels. Aching in both
arms & shoulders. Pt had a temp. of 39.1 at this time. Pt has
taken Datril one at 0116 and again at 0430 this am. No
meds. No doctor. No allergies
942
1009
88
98/60
124 80/Dopp
20
17
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Example # 1
Strengths?
• two complete sets of VS
en route to hospital
Improvements?
• disorganized
• skimpy (what was the
chief complaint?)
• recognize and treat
shock when your patient
has it
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Example # 2
1450
R/L
KVO
16 ga
LAB
R compound open femur fracture. Lacerations – inner R thigh, R ankle,
R toes, R little toe underneath. Abrasions – both elbows, 4 burn marks
1 ½” diameter in thoracic/lumbar region of back. femur fracture w/
bone coming thru medial aspect approx 3” above knee. Open wound
approx 3” long lateral aspect approx 2” above knee 1 open wound with
great deal of bleeding from medial aspect of wound. Contusions &
lacerations to tib/fib area of R leg. Pt. has good motor function of the
toes on the R leg and good distal pulse. Pt drowsy and difficult time
getting radial pulse. Pt had no guarding in abdomen breath sounds
good. NKA, NKM. Pt took off helmet and jacket prior to arrival.
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Vital Signs – Example # 2
1427
56
84/P
Both legs of
MAST inflated
1450
68
104/D
80
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Example # 2
Strengths?
• detailed descriptions of
injuries
• recognized and treated
shock
Improvements?
• What happened (how
was pt injured)?
• Pre-MAST vital signs?
• Was initial respiratory
rate really 80 per minute?
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Example # 3
68 y/o male found lying face down on bedroom floor, had
vomited. Pt responsive to verbal stimuli, could answer
questions with single words, but could not tell us what
happened or speak understandably. Able to move all
extremities, oriented to person only. Large contusion L
forehead, small abrasion on R forehead and upper bridge
of nose. Pupils constricted. Wife reports hx stomach
problems but was very upset, unable to give good history.
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Example # 3
Strengths?
• good description of
abnormal mental status
• good explanation for lack
of history
Improvements?
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Example #4
Arrived to find alert oriented X 3 28 y/o female c/o
substernal pain that started approx 4 hrs ago and has
been constant. Pain radiated into back. Skin warm, dry &
pink. Pain felt as something heavy. Lungs clear & equal
bilaterally. Had stress test earlier today – results unknown.
Transported with 10 lpm NRB in Fowler’s position. M: Axid.
A: N/A. I: Mitral valve prolapse. D: McDonald. S: 1988
Hysterectomy.
2000 108 128/96
24
2018
112 130/P
28
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Example # 4
Strengths?
• good description of
history of present illness
• two complete sets of vital
signs
Improvements?
• nonstandard
abbreviations
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Correcting Information
 Before form submitted:
• if small error, draw single line through it and initial
it
• agency may require date and time, too
• if large error, start new PCR
 Do NOT try to obliterate error
• appears EMT was trying to hide something
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Correcting Information
 After form submitted:
• if information important, EMT who wrote PCR
should use separate piece of paper to:
 note reason for addendum and why it was not in original
report
 note date and time of addendum
 describe additional or corrected information
• Attach to PCR
• On original form, write “See addendum”
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IV Fluids & Medications
IV fluids
When a slash separates two words in a box, the word to
the left of the slash is for IV fluids and the word to the
right is for medications.
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IV Fluids & Medications
Medications
When a slash separates two words in a box, the word to
the left of the slash is for IV fluids and the word to the
right is for medications.
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IV Fluids & Medications
Remember to extend the box lines before writing your
narrative.
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Exercise #2
 Work in small groups and organize the
information on the cards so that it fits the
SOAP or CHART format.
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Summary




Have a system for completing the PCR
Have someone else check the form
Beware spelling and punctuation pitfalls
Use non-transport form when appropriate
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