Charting
The Patient and Family • The average person has contact with 9-1-1 twice in their lifetime • Is it an emergency or not?
How much do you tell them about what’s going on? • What about confidentiality?
Radio Communications • Why do them? • Be concise • Use standard format
Radio report should include • Unit calling • Pt age and gender • Name of primary physician • Chief complaint • General condition • Pertinent history • Management • ETA
Repeat orders back to verify • Clarify prn
Report at ED bedside • Introduce pt. • Use same logical format • Include pertinent negatives and positives • Include information about allergies and meds
The written record • A story • Logical beginning • Logical ending • Bulk of the material in the middle • Report must be: • Complete • Accurate • Legible • Left at hospital before clearing call
Written record, cont. • Must be signed by both PIC and partner • Limit statements to the facts. • No assumptions or judgments
Charting, cont. • DON’T make discriminatory statements • Don’t swear on charts • “get the H**l out of my house” • Use quotations • Do use accepted abbreviations • Draw single line through errors and initial them
Document findings, especially pertinent negatives • Will you remember details in 27 years?
Pearls for charting • Don’t let your paperwork interfere with patient care • If information is not recorded, it was NOT DONE. • If you didn’t do it, don’t write it down • Don’t document opinions • If you forgot it, don’t forget it next time • If you ever need it, this is your only defense
Charting formats • Flow chart • Fills out the story • Must include baseline vitals, as well as at least one other set • Document times
Medications • Critical for DDx • Include dosage and dosing regimes for certain meds
Allergies • May influence treatment
SOAP format • Subjective • Beginning of story • Objective • Middle – most difficult part • Document head to toe • General assessment vs focused assessment
SOAP format, cont. • Assessment • Or R/O; what do you think is wrong? • Plan • What did you do to fix the problem? • What response did the patient have to your tx? • How was the patient physically transferred? • Bed rails up or down? • Whose care did you leave pt in?
Did you? • Record all information needed by others? • Adequately state all your observations about pt.? • Support your clinical impression? • List all care given to pt? • Use only recognized abbreviations? • And your partner sign the form?
And finally… • Is your information complete enough so that you could reconstruct the entire situation and defend your actions later if necessary?
CHEATED format • Complaint • History • Exam • Assessment • Treatment • Evaluation • Disposition
Refusals • Decision-making capacity • The ability to make an informed decision • Impaired decision making capacity • The inability to understand the nature of illness or injury, and the risks and consequences of refusing care
Impaired decision making capacity (IDMC) • Alcohol ingestion • Use of drugs • Altered mentation from any medical condition or trauma • Don’t use “competent” or incompetent”
IDMC • Don’t have impaired person sign refusal form • Treat and transport any person who is impaired
Documenting refusals • General appearance • Vitals • H & P • Mental status • Presence of drugs or alcohol • Assessment of decision making capacity • Risks explained and advice offered • Response to efforts by EMTs to provide care • Communications with law enforcement, family, OLMC, pt.
Patient refusal definitions • 18 y/o or older • No significant mechanism of injury • No significant signs of trauma • No acute medical condition • No behavioral conditions • No comorbid factors
Reporting requirements • Suspected abuse • Child • Elder • Dog bites
Summary • Document to establish a record of care provided • Document to protect yourself and agency from questions
