Documentation
Topics Principles and Purposes of  EMS Documentation Medical Terminology & Abbreviations Roles of Documentation Subjec...
Introduction Your written prehospital care  report (PCR) is the only true  factual record of events. Your PCR is your so...
Uses for PCR’s   Medical   Administrative   Research   Legal
Run data in a PCR helps agencies to       improve patient care.
Complete both the narrative andcheck-box sections of every PCR.
General Considerations Use appropriate medical  terminology. Use acceptable and approved  abbreviations and acronyms.  I...
Some systems use check boxes, some use bubble-sheets, and others use     electronic documentation
Times Whenever possible, record all  times from the same clock. When that is not possible, be  sure that all the clocks ...
Communications The communications with the  hospital are another important  item to document. Document ANY medical advic...
Pertinent Negatives Document all findings of your  assessment, even those that  are normal.
Oral Statements Whenever possible, quote the  patient—or other source of  information—directly.  Example: Bystanders stat...
Elements of Good Documentation    Accuracy    Legibility    Timeliness    Absence of alterations    Professionalism
The Proper Way to Correct a   Prehospital Care Report
Professionalism Never include slang, biased  statements, or irrelevant  opinions. Include only objective  information. ...
2 Narrative FormatsCHART                   SOAP     Chief complaint        Subjective     History                Objec...
Narrative Writing Subjective part of your narrative  comprises any information that you  elicit during your patient’s his...
Special Considerations Patient refusals Services not needed Mass casualty incidents
Patient Refusals Patients retain the right to refuse  treatment or transportation if they  are competent to make that  de...
A patient’s refusal of care requires      careful documentation.
One Example of a“Refusal of Care” Form
Services Not Needed Some systems allow paramedics to  determine patients that do not  require ambulance transportation. ...
Mass Casualty Incidents Multiple patients, mass casualties,  and disasters all present special  documentation problems. ...
Triage tags are used to record vitalinformation on each patient quickly.
Consequences ofInappropriate Documentation Inappropriate documentation can  have both medical and legal  consequences.  ...
Summary Principles and Purposes of  EMS Documentation Medical Terminology & Abbreviations Roles of Documentation Subje...
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Pt assess documentation

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  • 1. Medical audit a. Run review conferences b. Other educational forums 2. Quality improvement a. Tally the individual’s performance of patient care procedures and to review individual performance b. Identify systems issues regarding quality improvement 3. Billing and administration a. Acquire the necessary billing and administrative data 4. Data collection a. Research purposes
  • Let’s check out some abbreviations on page 794
  • a. Time of call b. Time of dispatch c. Time of arrival at the scene d. Time(s) of medication administration and certain medical procedures as defined by local protocol e. Time of departure from the scene f. Time of arrival at the medical facility (when transporting a patient) g. Time back in service
  • a. Mechanism of injury b. Patient’s behavior c. First aid interventions attempted prior to the arrival of EMS personnel d. Safety-related information, including disposition of weapons e. Information of interest to crime scene investigators f. Disposition of valuable personal property (e.g., watches, wallets)
  • A. Accurate 1. Document accuracy depends on all information provided, both narrative and checkbox, being a. Precise b. Comprehensive 2. All checkbox sections of a document must show that the EMT-Critical Care Technician attended to them, even if a given section was unused on a call 3. Medical terms, abbreviations, and acronyms are properly used and correctly spelled B. Legible 1. Legibility means that handwriting, especially in the narrative portion of the document, can be read by others without difficulty 2. Checkbox marking should be clear and consistent from the top page of the document to all underlying pages C. Timely 1. Documentation should be completed ideally before the EMT-Critical Care Technician handles tasks subsequent to the patient interaction D. Unaltered 1. While writing the document, should the EMT-Critical Care Technician make an error, a single line should be drawn through the error, initialed, and dated 2. Should alterations to a document be required after the document has been submitted, see “document revision/ correction” (below) E. Free of non-professional/ extraneous information 1. Jargon 2. Slang 3. Bias 4. Libel/ slander 5. Irrelevant opinion/ impression
  • Chart History of present illness Past History Current health status Assesment vitals, general impression, physical Assessment is your Field Diagnosis – includes pertinent negatives Plan (write under comments) treatments and ongoing assessment
  • Subjective is OPQRST Objective There are two ways to do this Head to toe approach vs body systems approach
  • Pt assess documentation

    1. 1. Documentation
    2. 2. Topics Principles and Purposes of EMS Documentation Medical Terminology & Abbreviations Roles of Documentation Subjective & Objective Documentation Evaluation of a Finished Document Special Situations
    3. 3. Introduction Your written prehospital care report (PCR) is the only true factual record of events. Your PCR is your sole permanent, complete written record of events during the ambulance call.
    4. 4. Uses for PCR’s Medical Administrative Research Legal
    5. 5. Run data in a PCR helps agencies to improve patient care.
    6. 6. Complete both the narrative andcheck-box sections of every PCR.
    7. 7. General Considerations Use appropriate medical terminology. Use acceptable and approved abbreviations and acronyms. If you do not know how to spell a word, look it up or use another word…
    8. 8. Some systems use check boxes, some use bubble-sheets, and others use electronic documentation
    9. 9. Times Whenever possible, record all times from the same clock. When that is not possible, be sure that all the clocks and watches you use are synchronized.
    10. 10. Communications The communications with the hospital are another important item to document. Document ANY medical advice or orders you receive and the results of implementing that advice and those orders.
    11. 11. Pertinent Negatives Document all findings of your assessment, even those that are normal.
    12. 12. Oral Statements Whenever possible, quote the patient—or other source of information—directly. Example: Bystanders state the patient was “acting bizarre and threatening to jump in front of the next passing car.”
    13. 13. Elements of Good Documentation  Accuracy  Legibility  Timeliness  Absence of alterations  Professionalism
    14. 14. The Proper Way to Correct a Prehospital Care Report
    15. 15. Professionalism Never include slang, biased statements, or irrelevant opinions. Include only objective information. Always write and speak clearly.
    16. 16. 2 Narrative FormatsCHART SOAP  Chief complaint  Subjective  History  Objective  Assessment  Assessment  Rx (treatment)  Plan  Transport
    17. 17. Narrative Writing Subjective part of your narrative comprises any information that you elicit during your patient’s history. Objective part of your narrative usually includes your general impression and any data that you derive through inspection, palpation, auscultation, percussion, and diagnostic testing.
    18. 18. Special Considerations Patient refusals Services not needed Mass casualty incidents
    19. 19. Patient Refusals Patients retain the right to refuse treatment or transportation if they are competent to make that decision. Two main types of refusals:  Person who is not seriously injured and does not want to go to the hospital  The patient refuses even though you feel he needs it.
    20. 20. A patient’s refusal of care requires careful documentation.
    21. 21. One Example of a“Refusal of Care” Form
    22. 22. Services Not Needed Some systems allow paramedics to determine patients that do not require ambulance transportation. While this may help to reduce ambulance utilization, the risks of denying transport are even greater than those of a refusal. Evaluate all patients with even minor injuries and document appropriately.
    23. 23. Mass Casualty Incidents Multiple patients, mass casualties, and disasters all present special documentation problems. Weigh your patient’s needs against the demand for complete documentation. Follow local guidelines and utilize the appropriate forms such as triage tags.
    24. 24. Triage tags are used to record vitalinformation on each patient quickly.
    25. 25. Consequences ofInappropriate Documentation Inappropriate documentation can have both medical and legal consequences.  Do not guess about your patient’s problems.  Write neatly, clearly, and legibly.  Complete your form completely.  Spelling counts!
    26. 26. Summary Principles and Purposes of EMS Documentation Medical Terminology & Abbreviations Roles of Documentation Subjective & Objective Documentation Evaluation of a Finished Document Special Situations

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