Proper Documentation Techniques

1. Proper Documentation Techniques TransCare Ambulance NorthWest February 2013

2. What is “Proper Documentation?” • Proper documentation adequately records the information about a patient contact which is required for billing, legal, payroll and demographic tracking. It includes:

3. Proper Documentation • Patient Name • Patient Address • Patient Insurance (If available) • Patient Date of Birth • Patient Social Security Number (If available) • Sending and Receiving Facility and Department • Sending and Receiving Facility Address • Sending and Receiving Physician • Times • Mileage • Patient Chief Complaint • Patient Secondary Complaints • Patient Pertinent Medical History • Patient Signs and Symptoms • Patient Assessment and Physical Findings • Patient Vital Signs • Medications Administered and Response • Procedures Performed and Response • Patient Belongings Disposition • Any Other Information Pertinent to the Ambulance Transfer

4. Paperwork Required • Every ambulance transfer must include the following paperwork: • Patient Contact Report(PCR) or Trip Report • Physician Certification Statement, also called Certificate of Medical Necessity (Even “wheelchair” transports require this paperwork as there is a section for non-medically necessary patients.) • Face Sheet or Patient Information Sheet • Disposable Supply Sheet • Patient Release of Information/HIPAA Signature Form • Advanced Beneficiary Notice(ABN) must be included on calls when the EMT reasonably believes that the patient’s insurance will not cover the expense of the trip due to lack of medical necessity or other reasons specified on the form.

5. Paperwork Cont. • When possible, you should include the following paperwork: • Physician’s Transfer Orders • Copy of the COBRA Form (when transferring from an E.R.) • Copies of the EKG • Driver Mileage and Tracking Sheet

6. Completed PCR • All PCRs must be completed and turned in within 24 hours of the completion of the call. This is required even if you are going off shift. You will be paid for the time spent completing your PCR. • The PCR must be completed using the State Bridge program provided by ImageTrend Software. It can be completed online or using the Field Bridge Software on the company laptops.

7. Narrative Techniques • The single most difficult part of proper documentation is writing a proper narrative. Narratives for ambulance transfers differ significantly from other forms of medical documentation like nurses notes. The D-SOAP format is the only acceptable narrative format for TransCare EMTs and Nurses.

8. D-SOAP • The D-SOAP method is the simplest way to ensure that all necessary information is included in each PCR. It also makes the PCRs simpler and faster to write by grouping information together in a standard format. • D-SOAP stands for: • Dispatched • Subjective Information • Objective Information • Assessment • Plan/Procedures

9. Dispatched • Each PCR should begin with a description of what you are dispatched to. It should also include a time frame for how you were dispatched. • “Dispatched to HPCC to transfer a female pt. to VVH due to abdominal pain. Transfer scheduled for 1400 hours. • “Dispatched to GRMC ED for an immediate transfer of a male pt. involved in an MVA to SMH ER. Pt reported as unresponsive.

10. Dispatched Cont. • Use of the term “emergent transfer” in the Dispatched section should be limited to calls in which an ambulance was dispatched immediately at the facilities request and to which the patient was taken to a higher level of care. Transfers from hospital to nursing homes may never be classified as “emergent.”

11. S.ubjective • The Subjective section is where you put the things that are told to you, either by the patient, family, bystanders, or medical personnel. Any known medical history, medications, allergies and other pertinent information about the current event should be recorded here.

12. S.ubjective BLS Example • “S. Upon arrival RN states pt. began suffering from abdominal pain at 0100. Pt has not vomited. Pt states pain is 4/10 and feels like cramps. Pt. denies chest pain, shortness of breath or nausea with this event. Pt. Hx of insulin dependent Type 2 diabetes and HTN. Pt. also has Hx of previous bowel obstructions. Current medications include an unknown dose of insulin and metoprolol. Allergies to Sulfa.”

13. S.ubjective ALS example • “U /A RN states pt. was brought in by ambulance 2 hours ago after being involved in a roll over MVA. States pt. was unrestrained and was ejected. CT showed multiple epidural and sub-arachnid bleeds as well as C3 and C4 compression fractures without spinal cord involvement. Pt has been unresponsive the entire time and could not provide any medical Hx.”

14. O.bjective • The Objective section is where you enter the things that you observe either on the patient or on your monitoring equipment. You should document how and where you find the patient here. This is also the section where you should interpret your EKG if you hook the patient up to the LifePak. Trauma patients should have complete physical exam documented here.

15. O.bjective BLS Example • “O. Found 63 YOF pt lying in her bed with RN in attendance. Pt. A & O x 3. Abdomen is soft and non tender in all four quadrants. Pt. does not react to palpation. Skin is pink, dry and slightly feverish. Vital signs listed below. Breath sounds = and clear bilaterally. Pupils PERRL.

16. O.bjective ALS Example • U / A found 18 YOM pt. unresponsive and secured to a long spinal board with C-Collar in place. VS listed below. HEENT – Head – large hematoma over left temple. Sutured 3 inch laceration over left eye. Eyes – Right pupil dilated and non-reactive. Left pupil 3mm and reactive. Ears – Atraumatic with no blood or fluid from the canal. Nose – Laceration on bridge of the nose that is not actively bleeding. Dried blood around both nares. Throat – No JVD or Tracheal Deviation noted.

17. O.bjective ALS Example Cont. • CTLS – Unable to assess due to immobilization on backboard. CT showed Fx to both C3 and C4. • Chest – Abrasions along left chest with some associated bruising. BS = and clear bilaterally. No crepitus noted. EKG showed Sinus Tach. without ectopy. • Abd. – Apparently atraumatic. SNT in all four quads. • Pelvis – Stable with out crepitus. • Extremities – Unable to assess sensation or movement. Left arm is immobilized in a splint due to multiple forearm fxs. IV in place in RAC with Dopamine drip running @ 500mcg/minute.

18. A.ssessment • This section should include your assessment of the patient’s probable medical issue related to the transfer. If available, it should include the doctor’s assessment as well. • BLS – “A. Abd. Pain. R/O Bowel obstruction, R/O infection.” • ALS – “MVA, Multiple Closed Head Injuries, C-Spine Fxs, Left arm Fxs.”

19. P.lan/P.rocedures • This section should include all of your actions from the time you arrive at the facility to the time you drop off the patient. You should include a description of how the patient was moved to the gurney and from the gurney to the bed at the receiving facility. All medications and procedures performed, as well as the patients response to the procedures must be documented here.

20. P.lan/P.rocedure BLS Example • P. Arrived and received report from RN. Hx. And exam of pt. Pt. walked to gurney and was secured. O2 @ 3 LPM via NC. Transport non-emergent to VVH ACU. Vital Signs every 15 minutes. No changes in pt. during transport. Care transferred to VVH nursing staff with report. Pt. belongings bag left in care of the pt.

21. P.lan/P.rocedure ALS Example • Arrived and received report from Dr. Kevan. Pt still secured to long spine board. Pt lifted to pram and secured. O2 @ 10 LPM via NRB. Cardiac Monitor. Dopamine moved to our pump and infusion continued @ 500mcg/hour. VS q. 5 min. 2mg Ativan given IV push @ 0534 due to apparent seizure activity. Seizure controlled with Ativan. Upgraded to Code 3. Transport with no further incidents or patient changes. Care turned over to SMH ED Staff with report.

22. Other Methods • Many EMTs and Nurses utilize other methods of reporting, like the Story Method where the writer tells a story of what happened during the call. While this is often an easier and quicker than the D-SOAP method, it is less reliable and is not an acceptable format for TransCare employees.

23. Conclusion • The DSOAP method of documentation provides the most accurate and thorough method of recording your patient contact. This method is the only acceptable format for TransCare Patient Contact Reports. With practice, this method will prove to be faster and more accurate for your PCRs.