Documentation Brown EMS October 18, 2007
Reasons for Documentation <ul><li>Continuation of care </li></ul><ul><ul><li>Medications </li></ul></ul><ul><ul><li>Physic...
If you didn’t write it down  it didn’t happen
A good report is… <ul><li>Concise </li></ul><ul><li>Accurate </li></ul><ul><li>Consistent in style </li></ul><ul><li>Addre...
Styles
SOAP <ul><li>Subjective- symptoms </li></ul><ul><li>Objective- physical exam, vital signs </li></ul><ul><li>Assessment- di...
Review of Systems <ul><li>General appearance, skin color, level of distress </li></ul><ul><li>HEENT head, ears, eyes, nose...
Physical exam techniques <ul><li>Inspect </li></ul><ul><li>Palpate </li></ul><ul><li>Percuss  </li></ul><ul><li>Auscultate...
Head to toe exam <ul><li>Mental status  A+Ox3, PERRL, gait, speech </li></ul><ul><li>Skin –  Warm, Dry, Color – Normal, ra...
General EMS Report format <ul><li>Chief complaint </li></ul><ul><li>Meds </li></ul><ul><li>PMH </li></ul><ul><li>Allergies...
Chief Complaint <ul><li>Why is the patient seeking medical care </li></ul><ul><li>Use the patient’s own words if possible ...
History of Present Illness <ul><li>Details about the chief complaint </li></ul><ul><li>Includes pertinent negatives </li><...
Some important mnemonics <ul><li>PAIN </li></ul><ul><li>OPQRST </li></ul><ul><ul><li>Onset </li></ul></ul><ul><ul><li>Prov...
Medical History <ul><li>Surgical history </li></ul><ul><li>OB History (if related to chief complaint) </li></ul><ul><li>Fa...
Vital Signs <ul><li>BP </li></ul><ul><li>Pulse - rate, regularity, quality </li></ul><ul><li>Respiration Rate </li></ul><u...
Physical exam findings <ul><li>Mental status </li></ul><ul><li>Skin </li></ul><ul><li>Pupils </li></ul><ul><li>Neuro </li>...
Treatment <ul><li>Exam findings should support treatment </li></ul><ul><li>CSM before & after splinting / c spine </li></u...
Chest pain differential diagnosis <ul><li>Cardiac </li></ul><ul><ul><li>MI, angina, pericarditis </li></ul></ul><ul><li>Ao...
Chest pain/cardiac <ul><li>OPQRST </li></ul><ul><li>Shortness of breath </li></ul><ul><li>Nausea /Vomiting </li></ul><ul><...
 
Trauma Differential <ul><li>Head injury/bleed </li></ul><ul><li>Airway compromise </li></ul><ul><li>C spine fracture </li>...
Trauma <ul><li>AMPLE </li></ul><ul><li>Mechanism of injury </li></ul><ul><ul><li>Speed, type of vehicle, restrained, helme...
 
Abdominal pain differential <ul><li>Appendicitis </li></ul><ul><li>Ectopic pregnancy or other OB emergency </li></ul><ul><...
Abdominal pain <ul><li>Surgeries </li></ul><ul><li>OPQRST </li></ul><ul><li>Nausea, vomiting diarrhea </li></ul><ul><li>Re...
 
Headache differential <ul><li>Head bleed, CVA </li></ul><ul><li>trauma </li></ul><ul><li>Migraine </li></ul><ul><li>Stress...
Headache <ul><li>Trauma </li></ul><ul><li>Photophobia </li></ul><ul><li>Nausea/ vomiting </li></ul><ul><li>Stiff neck, bac...
Head Injury <ul><li>Trauma </li></ul><ul><li>Photophobia </li></ul><ul><li>Nausea/ vomiting </li></ul><ul><li>Stiff neck, ...
Refusal <ul><li>Must be well documented </li></ul><ul><li>Thorough history and physical exam </li></ul><ul><li>Complete vi...
Things to avoid <ul><li>Exam was unremarkable </li></ul><ul><li>Pt was intoxicated…refused treatment </li></ul><ul><li>Any...
 
Bubbles <ul><li>Research code - undergrad, grad, faculty, etc. list is posted in supervisors office </li></ul><ul><li>Cens...
 
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Documentation CME 2007

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Documentation CME 2007

  1. 1. Documentation Brown EMS October 18, 2007
  2. 2. Reasons for Documentation <ul><li>Continuation of care </li></ul><ul><ul><li>Medications </li></ul></ul><ul><ul><li>Physical exam findings, trends </li></ul></ul><ul><li>Continuous Quality Improvement </li></ul><ul><li>Protocol adherence </li></ul><ul><li>Legal Protection </li></ul>
  3. 3. If you didn’t write it down it didn’t happen
  4. 4. A good report is… <ul><li>Concise </li></ul><ul><li>Accurate </li></ul><ul><li>Consistent in style </li></ul><ul><li>Addresses chief complaint </li></ul><ul><li>Demonstrates professional and appropriate care of patient </li></ul>
  5. 5. Styles
  6. 6. SOAP <ul><li>Subjective- symptoms </li></ul><ul><li>Objective- physical exam, vital signs </li></ul><ul><li>Assessment- differential diagnosis </li></ul><ul><li>Plan- treatment, follow up </li></ul>
  7. 7. Review of Systems <ul><li>General appearance, skin color, level of distress </li></ul><ul><li>HEENT head, ears, eyes, nose and throat </li></ul><ul><li>Neuro- A+Ox3, pupils, gait, speech, affect, intoxication </li></ul><ul><li>Cardiovascular- HR, BP, Heart sounds, JVD, </li></ul><ul><li>Pulmonary- lung sounds, RR, percussion, SpO2 </li></ul><ul><li>GI/GU- palpation, </li></ul><ul><li>Musculoskeletal- fractures, strength, </li></ul><ul><li>Integumentary </li></ul>
  8. 8. Physical exam techniques <ul><li>Inspect </li></ul><ul><li>Palpate </li></ul><ul><li>Percuss </li></ul><ul><li>Auscultate (before palpate on abdominal exam) </li></ul>
  9. 9. Head to toe exam <ul><li>Mental status A+Ox3, PERRL, gait, speech </li></ul><ul><li>Skin – Warm, Dry, Color – Normal, rashes? </li></ul><ul><li>Head- trauma, airway </li></ul><ul><li>Neck- trauma, (c spine) tenderness, stridor, JVD, trachea midline </li></ul><ul><li>Chest- lung sounds, trauma, heart sounds, percuss, </li></ul><ul><li>Abdomen - soft, tender, masses, pulsations, scars </li></ul><ul><li>Pelvis - Stable, tenderness </li></ul><ul><li>Extremeties - distal csm, trauma </li></ul>
  10. 10. General EMS Report format <ul><li>Chief complaint </li></ul><ul><li>Meds </li></ul><ul><li>PMH </li></ul><ul><li>Allergies </li></ul><ul><li>Circumstances of call (dispatch, location) </li></ul><ul><li>HPI (Symptoms) </li></ul><ul><li>PE (Signs) </li></ul><ul><li>Tx (includes transport or refusal) </li></ul><ul><li>Response to Tx </li></ul>
  11. 11. Chief Complaint <ul><li>Why is the patient seeking medical care </li></ul><ul><li>Use the patient’s own words if possible </li></ul>
  12. 12. History of Present Illness <ul><li>Details about the chief complaint </li></ul><ul><li>Includes pertinent negatives </li></ul><ul><li>Pertinent negatives- important information that helps narrow your differential diagnosis </li></ul>
  13. 13. Some important mnemonics <ul><li>PAIN </li></ul><ul><li>OPQRST </li></ul><ul><ul><li>Onset </li></ul></ul><ul><ul><li>Provocation </li></ul></ul><ul><ul><li>Quality </li></ul></ul><ul><ul><li>Radiation </li></ul></ul><ul><ul><li>Severity </li></ul></ul><ul><ul><li>Timing </li></ul></ul><ul><li>PHTLS </li></ul><ul><li>AMPLE </li></ul><ul><ul><li>Allergies </li></ul></ul><ul><ul><li>Medications </li></ul></ul><ul><ul><li>Past Medical History </li></ul></ul><ul><ul><li>Last Meal </li></ul></ul><ul><ul><li>Events preceding </li></ul></ul>
  14. 14. Medical History <ul><li>Surgical history </li></ul><ul><li>OB History (if related to chief complaint) </li></ul><ul><li>Family history </li></ul><ul><li>Medications and allergies </li></ul><ul><li>Major illnesses </li></ul><ul><li>Current ongoing illness </li></ul>
  15. 15. Vital Signs <ul><li>BP </li></ul><ul><li>Pulse - rate, regularity, quality </li></ul><ul><li>Respiration Rate </li></ul><ul><li>Temperature - specify route, PO/PR </li></ul><ul><li>Pain, 1-10 </li></ul><ul><li>Glucose </li></ul><ul><li>SpO2 </li></ul>
  16. 16. Physical exam findings <ul><li>Mental status </li></ul><ul><li>Skin </li></ul><ul><li>Pupils </li></ul><ul><li>Neuro </li></ul><ul><li>Lung sounds </li></ul><ul><li>Chest </li></ul><ul><li>Abdomen </li></ul><ul><li>Exam should be focused on chief complaint </li></ul><ul><li>All documentation should include mental status, general appearance. </li></ul>
  17. 17. Treatment <ul><li>Exam findings should support treatment </li></ul><ul><li>CSM before & after splinting / c spine </li></ul><ul><li>Meds: time, dose, route </li></ul><ul><li>Response to treatment </li></ul><ul><li>Transport </li></ul>
  18. 18. Chest pain differential diagnosis <ul><li>Cardiac </li></ul><ul><ul><li>MI, angina, pericarditis </li></ul></ul><ul><li>Aortic Aneurysm </li></ul><ul><li>Pulmonary </li></ul><ul><ul><li>Pneumonia, Pulmonary Embolism, Pneumothorax </li></ul></ul><ul><li>Musculoskeletal </li></ul><ul><li>GI </li></ul>
  19. 19. Chest pain/cardiac <ul><li>OPQRST </li></ul><ul><li>Shortness of breath </li></ul><ul><li>Nausea /Vomiting </li></ul><ul><li>Weakness, dizziness </li></ul><ul><li>Diaphoresis </li></ul><ul><li>Orthopnea </li></ul><ul><li>Nocturnal dyspnea </li></ul><ul><li>Past MI, FHx </li></ul><ul><li>?diabetes </li></ul><ul><li>Lung sounds </li></ul><ul><li>JVD </li></ul><ul><li>EKG </li></ul><ul><li>BP, HR, RR </li></ul><ul><li>Pulses </li></ul><ul><li>Cap refill </li></ul><ul><li>Skin color, condition </li></ul><ul><li>edema </li></ul>
  20. 21. Trauma Differential <ul><li>Head injury/bleed </li></ul><ul><li>Airway compromise </li></ul><ul><li>C spine fracture </li></ul><ul><li>Pneumothorax </li></ul><ul><li>Hemorrhage / hypotension </li></ul><ul><li>GSW, stab wounds, occult injuries </li></ul><ul><li>ETC. </li></ul>
  21. 22. Trauma <ul><li>AMPLE </li></ul><ul><li>Mechanism of injury </li></ul><ul><ul><li>Speed, type of vehicle, restrained, helmet </li></ul></ul><ul><li>Ambulatory? </li></ul><ul><li>LOC </li></ul><ul><li>Change in mental status </li></ul><ul><li>vomiting </li></ul><ul><li>Airway </li></ul><ul><li>Lung sounds </li></ul><ul><li>Mental status </li></ul><ul><li>C spine </li></ul><ul><li>Vital signs </li></ul><ul><li>PERRL </li></ul><ul><li>Head, neck </li></ul><ul><li>Chest and back </li></ul><ul><li>Pelvis </li></ul><ul><li>Extremeties- csm, trauma </li></ul>
  22. 24. Abdominal pain differential <ul><li>Appendicitis </li></ul><ul><li>Ectopic pregnancy or other OB emergency </li></ul><ul><li>Ischemic bowel </li></ul><ul><li>AAA </li></ul><ul><li>Ulcer </li></ul><ul><li>Esophageal varicies </li></ul><ul><li>Pancreatitis </li></ul><ul><li>Trauma (spleen) </li></ul><ul><li>GERD </li></ul><ul><li>Infection/ food poisoning </li></ul><ul><li>Gastritis </li></ul><ul><li>Renal </li></ul><ul><li>Location, location… </li></ul>
  23. 25. Abdominal pain <ul><li>Surgeries </li></ul><ul><li>OPQRST </li></ul><ul><li>Nausea, vomiting diarrhea </li></ul><ul><li>Recent meals </li></ul><ul><li>Pregnancy </li></ul><ul><li>Last bowel movement </li></ul><ul><li>Last Menstrual Period </li></ul><ul><li>Unusual bleeding </li></ul><ul><li>Mental status </li></ul><ul><li>Skin color, temp </li></ul><ul><li>PO temp </li></ul><ul><li>Bowel sounds </li></ul><ul><li>Soft, rigid, masses, pulsation, tenderness, guarding </li></ul><ul><li>Rebound tenderness </li></ul><ul><li>Distal pulses- femoral, pedal </li></ul>
  24. 27. Headache differential <ul><li>Head bleed, CVA </li></ul><ul><li>trauma </li></ul><ul><li>Migraine </li></ul><ul><li>Stress </li></ul>
  25. 28. Headache <ul><li>Trauma </li></ul><ul><li>Photophobia </li></ul><ul><li>Nausea/ vomiting </li></ul><ul><li>Stiff neck, back </li></ul><ul><li>Fever </li></ul><ul><li>LOC </li></ul><ul><li>Visual problems </li></ul><ul><li>PEERL </li></ul><ul><li>OTC meds </li></ul><ul><li>Coumadin? </li></ul>
  26. 29. Head Injury <ul><li>Trauma </li></ul><ul><li>Photophobia </li></ul><ul><li>Nausea/ vomiting </li></ul><ul><li>Stiff neck, back </li></ul><ul><li>Fever </li></ul><ul><li>LOC </li></ul><ul><li>Visual problems </li></ul><ul><li>PEERL </li></ul><ul><li>OTC meds </li></ul><ul><li>Coumadin? </li></ul><ul><li>ETOH </li></ul>
  27. 30. Refusal <ul><li>Must be well documented </li></ul><ul><li>Thorough history and physical exam </li></ul><ul><li>Complete vital signs </li></ul><ul><li>Against medical advice </li></ul><ul><li>Notification of risks including death or disability by refusing care </li></ul><ul><li>Signs and symptoms to look for </li></ul><ul><li>Follow up instructions given to patient </li></ul>
  28. 31. Things to avoid <ul><li>Exam was unremarkable </li></ul><ul><li>Pt was intoxicated…refused treatment </li></ul><ul><li>Anything crossed out or added in report. If you need to add information add it at the end N.B. </li></ul><ul><li>Treatment inconsistent with report. </li></ul><ul><li>Incomplete vitals </li></ul>
  29. 33. Bubbles <ul><li>Research code - undergrad, grad, faculty, etc. list is posted in supervisors office </li></ul><ul><li>Census tract - East or West of Thayer St. </li></ul><ul><li>Service Number- 0092 </li></ul><ul><li>VHCL# - 01 or 02 </li></ul><ul><li>Please fill in all appropriate fields </li></ul><ul><li>Fill in bubbles completely </li></ul><ul><li>Only one primary suspected illness </li></ul>
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