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    Documentation Documentation Presentation Transcript

    • Chapter 4Documentation
    • • Objectives: – At the end of this module the student will be able to • Define the PCR (Patient Care Report) • Discuss the functions of the PCR • Discuss the different methods of documenting the PCR • Discuss what to do when errors occur • Discuss documentation surrounding a “refusal” of care/procedure • Discuss special reporting situations • Discuss medical terminology
    • Reading Assignment and Test Information• Take a moment to read the following in your textbook – AAOS Emergency Care and Transportation of the Sick and Injured Tenth Edition • Pages 119-126
    • National EMS Education Standard CompetenciesDocumentation – Recording patient findings – Principles of medical documentation and report writingMedical TerminologyUses foundational anatomic and medicalterms and abbreviations approved within yoursystem.
    • • Documentation – Patient’s permanent medical record – Demonstrates appropriate care was delivered – Helps others in patient’s future care
    • Documentation• The PCR serves six functions: – Continuity of care – Legal documentation – Education – Administrative information – Evaluation and continuous quality improvement
    • Patient Care Reports• Information collected on the PCR includes: – Chief complaint – Level of consciousness or mental status – Vital signs – Initial assessment – Patient demographics
    • Types of Forms • Traditional written form with: – Check boxes – Narrative section • Computerized versionSource: Courtesy of the Utah Department of Health
    • Types of Forms• The narrative section of the PCR may be the most important.• Includes: – Time of events – Assessment findings – Emergency medical care provided
    • Types of Forms• Narrative section (cont’d): – Changes in patient after treatment – Observations at the scene – Staff person who continued care
    • Reporting Errors• If you leave something out or record it incorrectly, do not try to cover it up.• Falsification: – Results in poor patient care – May result in suspension and/or legal action
    • Refusal of Care• A common source of lawsuits. – Thorough documentation is crucial.• Document any assessment findings and emergency medical care given.• Have patient sign a refusal form. – Have family member, police officer, or bystander also sign as witness.• Complete the PCR.
    • Special Reporting Situations• Depending on local requirements: – Gunshot wounds – Dog bites – Some infectious diseases – Suspected physical or sexual abuse – Mass-casualty incident (MCI)
    • Medical Terminology• Common terminology among all medical providers• Medical personnel around the globe speak same language• Taking a medical terminology course can be helpful.
    • Different Methods of Documenting• CHART or CHARTE method – C: chief complaint – H: history and physical examination – A: assessment – R: treatment (Rx) – T: transport – E: if using the CHARTE the “E” stands for exceptions• SOAP method – S: subjective – O: objective – A: assessment – P: patient care
    • Different Methods of Documenting• The CHEATED method – C chief complaint – H history – E exam – A assessment – T treatment – E evaluation – D disposition
    • Summary• Hope you enjoyed the review. Please remember to read the chapter and review this presentation as often as needed in preparation for the test.
    • Review5. Which of the following statements about the patient care report (PCR) is true? A. It is not a legal document in the eyes of the law. B. It cannot be used for patient billing information. C. It helps ensure efficient continuity of patient care. D. It is for use only by the prehospital care provider.
    • ReviewAnswer: CRationale: The PCR is an importantdocument for more than one reason. It helpsto ensure efficient continuity of patient care byproviding the hospital with an account of allprehospital assessments and treatment. Italso serves as a legal document that reflectsthe care provided by the EMT.
    • Review (1 of 2)5. Which of the following statements about the prehospital care report is true? A. It is not a legal document in the eyes of the law. Rationale: A prehospital care report is a legal document. B. It cannot be used for patient billing information. Rationale: A prehospital care report can be used by hospital administration, which includes the billing department.
    • Review (2 of 2)5. Which of the following statements about the prehospital care report is true? C. It helps ensure efficient continuity of patient care. Rationale: Correct answer D. It is for use only by the prehospital care provider. Rationale: While it may not be read immediately by the hospital, it can be used later to review patient care procedures and for quality improvement purposes.
    • Summary• The PCR is a legal form• There are different methods of documentation• Everyone makes mistakes• Be detailed on all refusal of care• If you have any questions or comments please use the “classroom” area within the discussion board.
    • Credits• Slide Background Image (ambulance): © Galina Barskaya/ShutterStock, Inc.• Slide Background Images (non-ambulance): © Jones & Bartlett Learning. Courtesy of MIEMSS.