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Prehospital Documentation

Prehospital Documentation. Westchester County Department of Emergency Services. Objectives. Identify the communication and documentation considerations for EMT’s, EMT/I’s and Paramedics. I want YOU to write a great PCR!. Objectives. Required Data and “why” it’s required

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Prehospital Documentation

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  1. Prehospital Documentation Westchester County Department of Emergency Services www.westchestergov.com

  2. Objectives • Identify the communication and documentation considerations for EMT’s, EMT/I’s and Paramedics I want YOU towrite a great PCR! www.westchestergov.com

  3. Objectives • Required Data and “why” it’s required • The Do’s and the Don’ts • Types of Forms • Reporting Errors Identify the following: www.westchestergov.com

  4. First Things First…. www.westchestergov.com

  5. Baseline Information • Patient Information • Chief complaint • LOC or mental status • Vital signs www.westchestergov.com

  6. Non Patient Care Information ActivationTime • Time EMS dispatched • Time EMS enroute • Time EMS arrived at scene • Time EMS unit left scene • Time EMS unit arrived at hospital • Time patient care was transferred Travel Time Scene Time www.westchestergov.com

  7. Problems….. • Information recorded incorrectly or left out • write down what did or did not happen • steps taken to correct situation • Falsifying information www.westchestergov.com

  8. If You Make a Mistake…. ------------------ • Draw line through error • Initial and date • Write correct info next to it • May add note with correct info • Do not erase or use correction fluid www.westchestergov.com

  9. Examples of Data Collection • Written form • Computerized www.westchestergov.com

  10. Good documentation reduces: • Litigation • Complaints • Therefore reduces overall risk to the EMS agency, profession, and YOU! www.westchestergov.com

  11. QA & Research • Better ways and methods for patient care • Protocols get changed www.westchestergov.com

  12. QA & Research • Potential problems identified • Best practices identified www.westchestergov.com

  13. PCR Writing – THE ACT! www.westchestergov.com

  14. Why Write a PCR? • Prehospital care report serves six functions: • Continuity of care • Legal documentation • Education • Administrative • Research • Evaluation and quality improvement www.westchestergov.com

  15. Remember……… • Write clearly. • Be objective. • Be accurate. • If you didn’t write it, you didn’t do it. www.westchestergov.com

  16. Remember……… • Don’t pre-judge • What’s the worse that could be going on • Be without bias or prejudice • Chronic patients (Regulars) • Wipe the slate clean www.westchestergov.com

  17. Remember……… • State things concisely. • Use short succinct sentences. • K.I.S.S. • Avoid long winded statements. • Abbreviations (Accepted list). www.westchestergov.com

  18. PCR’s Must Be…. • Legible • All in the same time frame • Clear, not vague • Easy to read • Accurate • Truthful www.westchestergov.com

  19. VITAL VISION • Never record falsely, exaggerate, or make up data • Incorrect spelling, grammar, and punctuation can be misleading, and makes you look uneducated. • Objective information should be stated in a factual manner www.westchestergov.com

  20. Things to Think About…… • Avoid/Hyphen- (minus/negative) • Semicolon; Connect related statements instead of using “Patient states” • Colon: A colon can be used instead of “is” www.westchestergov.com

  21. The 4 “P’s” • Protection • Providers • Patient • Profession www.westchestergov.com

  22. Profession • Data • Quality Improvement • Risk Management • Research www.westchestergov.com

  23. Rule #1 “DO NO HARM” • Know your protocols • Not sure? Speak to Medical Control • Be objective with your treatment • You never know it all. • Rule #2 “USE COMMON SENSE” www.westchestergov.com

  24. You are not judge and jury. • Try to do an assessment. • Inform patient of ramifications. • Must be an informed refusal. • If they are: suicidal, have impaired judgment from drugs/alcohol..They have to be transported. • Minors can’t refuse to go, contact Medical Control. www.westchestergov.com

  25. Get a signed refusal, witnessed preferably by someone other than your partner • Document, document, document,……. • Cancelled, unfounded, left before arrival etc. Document, document, ….. www.westchestergov.com

  26. “You are going to wait for hours in the E.D. before you get seen.” • “An ambulance is going to cost you $$$$” • “Oh, you don’t want to go, okay see ya” • “They wont do anything for you” • “Someone could be dying while you’re tying us up with your bull #&^%” www.westchestergov.com

  27. “This could be related to your heart, it would be a good idea if you get checked out” • “You bent the steering wheel with your chest, there is serious potential for internal injuries” • “You know your family isn’t going to leave you alone unless you go” www.westchestergov.com

  28. Patient • Document what is found at the scene • Document patients condition • Provide subsequent providers with information to continue care www.westchestergov.com

  29. Scene Assessment • “Food rotting on counter tops” • “Apartment cold, heat turned off” • “Refrigerator empty” • “Large pile of newspapers and mail” • “Lives alone unable to get out of bed” • “On the floor for 24 hrs, lg urine stain” www.westchestergov.com

  30. Condition • “Appeared in poor hygiene” • “Incontinent of old urine and feces” • “Lethargic prior to O2 and warming” • “Talking to relatives not there” • “Bradycardia” www.westchestergov.com

  31. The Continuum • Medications • Allergies • Family contacts • Findings/Treatment/Changes • Written Run Report www.westchestergov.com

  32. The Major Malfunction… • Chief Complaint ; “I have chest pain”, “I’m dizzy”, “I can’t breath” What the patient c/o. • If unable to communicate ; Call nature (Man down), (Female collapsed) Use common sense judgment if it’s an unknown. • Came in as an unknown , friend states pt. drank a fifth of whiskey. www.westchestergov.com

  33. Other examples of Subjective • Prior level of function • Lifestyle/home situation, scene survey • History from patient and witnesses • Major complaints • Emotions or attitudes • Goals • Response to treatment www.westchestergov.com

  34. Patient, Patient, Patient! Subjective should be brief and to the point. It is acceptable to use “Patient” the 1st time, after that it’s assumed, unless otherwise stated, that the information in this section came from the patient www.westchestergov.com

  35. Check Please! • Put your narrative in chronological order with past medical history, history of present illness/injury, and changes as they occur. • It makes your report easier to read and make sense. • Do it the same way, EVERY TIME! www.westchestergov.com

  36. The Patient Says…. • Quoting can be the most appropriate method of conveying subjective information. • Verbs States, describes, denies, indicates, c/o. • Denial: “I don’t need to go to the hospital.” • Abusive language: “Keep your F#^%( hands off of me!” www.westchestergov.com

  37. Don’t Go It Alone….. • All of the following information was taken from the patient’s daughter: Lives with daughter and daughter’s husband. • Per wife: “He hasn’t been feeling well for several days.” www.westchestergov.com

  38. Objective / Observations • Measurements performed by the EMT. • Observations by the EMT. • Compared results from treatment. • Primary and Secondary surveys. www.westchestergov.com

  39. When I Look at the Patient I See…. • State of consciousness: A V P U , grimaces to pain, moans to voice, answers questions but is sleepy. • General Appearance: Thin, Obese, Pink, warm, and dry, unkempt…….. • Ataxic gait. • Grip strength weaker on left. • Breath sounds: Clear to auscultation. (CTA). www.westchestergov.com

  40. Assessment • Summary of the patients major problems. • Your sixth sense of what's going on. • Your impression. • Gives a reference point for others. www.westchestergov.com

  41. Examples ….. • Chest pain, r/o M.I. • Acute abdominal pain, r/o etiology. • Acute exacerbation of COPD. • Respiratory arrest, 2° to exacerbation of asthma. • Multi-system Trauma. www.westchestergov.com

  42. Examples ….. • Your written note must justify your treatment. • If you omitted treatment make it clear why. • If it’s not a standing order, Medical Control must be documented and orders received. • Who gave you the orders to treat or withhold Rx. www.westchestergov.com

  43. P L A N of care • Patient’s treatment plan (What you did) • Treatment progression • Plans for assessment and reassessment • Destination • Equipment used • Medications used • Transfer of care • Involvement of other agencies www.westchestergov.com

  44. Subjective • Don’t list irrelevant info. Info should demonstrate need for an ambulance. • Chief complaint, brief and to the point. • Rate pain on Borg Scale. • Avoid documenting chronic complaints. • Changes in mentation or function. www.westchestergov.com

  45. Objective • Show baseline assessment. • Document changes. • Take vital signs, Q-15 min. if stable, Q-10 or less if unstable. At least two sets needed to determine stability. • Re-evaluate patient at least once document change or no change. • Be careful in reporting mental status. www.westchestergov.com

  46. Assessment • Suspected problem. • R/O or R/I conditions you are treating for or strongly suspect. • If unsure describe what you see. www.westchestergov.com

  47. Plan • Treatment make it match the S, O, and A • Appropriate destination • If your agency bills for service: Medicare and Medicaid will audit and demand return of money www.westchestergov.com

  48. RMA • Document assessment findings and care given or attempted. • Have the patient sign the form. • Have a witness sign the form. (Not Partner). • Include a statement that you explained the consequences of refusing care to the patient. www.westchestergov.com

  49. Reportable Issues • Be familiar with required reporting in Westchester County, OSHA and your Agency. • Gun shot wounds (crime scene). • Animal bites. • Infectious disease exposure. • Suspected physical or sexual abuse. • Elder or Child abuse. • Multiple casualty incidents. www.westchestergov.com

  50. Reporting • Child, elderly, and disabled. • Mandated reporters. • Anonymous. • Follow up. www.westchestergov.com

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