5)Documentation
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5)Documentation

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    5)Documentation 5)Documentation Presentation Transcript

    • Documentation
    • Prehospital Pt Care Report (PPCR)
      • What
        • Standardized pt record used in EMS
        • Systematic collection of data from dispatch through tx to hospital
      • Functions
        • Documentation of
          • pt C/C, MOI, NOI, Hx, and treatments, refusals
      • Some items
        • Time – Location – Assessments – Rx – Changes in Condition
    • PPCR Functions
      • Medical Record
        • Continuity of Care
          • Medical report of prehospital care
          • Physician review for treatment
          • MOI, NOI, Chronology of S/S, Vitals, etc
      • Educational
        • Demonstrates proper documentation
        • How to handle unusual situations/events
      • Administrative
        • Billing
        • Service Statistics
        • Research
        • Evaluation/CE
        • Continuous QI
          • Improving different components of EMS through evaluation of call sheets and pt Rx
    • PPCR Functions
      • Legal Document
        • PROTECTION FROM LAWSUITS
        • IF YOU DON’T WRITE IT DOWN YOU DIDN’T DO IT!!!!!!!!
        • Generally the writer is the one who goes to court with the PPCR
        • Accurate times
        • Status of pt upon arrival at scene, during tx
        • Emergency treatment provided
        • Changes in condition en route to hospital
        • Any unusual events that occurred during the call
    • PPCR Components Minimal Data Set
      • Pt Information
        • C/C
        • LOC
        • Vital signs
          • B/P
          • Perfusion status
          • Pulse Rate
          • Resp Rate and Quality
          • Skin Color and Temp
      • Administrative Information (Military Time)
        • Time call was reported
        • Time unit signed en route
        • Time unit arrived on scene
        • Time of arrival at pt
        • Time unit left scene
        • Time of arrival at destination
        • Time of transfer of care
    • PPCR Types/Sections
      • Types
        • Traditional written form
        • Digital/Computer based
      • Run Data
        • Date – Times – Unit # - Service – Crew Names
      • Pt Data
        • Name – Address- DOB – Insurance Info – Sex – Age
        • NOI/MOI – Pt Location – Rx given prior to arrival
        • S/S – Rx administered – Baseline Vitals – SAMPLE Hx
        • Changes in condition -Receiving Facility – Specialty Tx mode
        • Rationale for receiving facility
      • Check Boxes
        • Be sure to fill in box completely
        • Avoid stray marks
    • PPCR Narrative
      • Narrative
        • Describe, don’t conclude
        • Include pertinent negatives
        • Record observations about the scene
        • Avoid radio codes
        • Use standard abbreviations
        • When sensitive information is obtained note the source
        • State reporting requirements
        • Spell correctly
        • For EVERY assessment record time and findings.
    • Narrative Methods
      • C.H.A.R.T.
        • C omplaint
        • H istory
        • A ssessment
        • R x-Treatment
        • T ransport
      • S.O.A.P
        • S ubjective
          • What Pt/bystanders says in their “own words”
            • C/C, SAMPLE/OPQRST
        • O bjective
          • What YOU see/measure in assessment
            • Scene size up, Assessment findings, Vitals,
        • A ssessment
          • What YOU think is wrong
            • Conclusion/Clinical impression
        • P lan
          • Treatments occurred, treatments planned
      • C.H.E.A.T.E.D.
        • C hief Complaint
        • H istory
        • E xamination
        • A ssessment
        • T reatment
        • E valuation
          • Did treatment help
        • D isposition
          • Final outcome
    • PPCR Distribution
      • Confidentiality
        • The form and its contents are confidential
      • Distribution
        • Determined by local and state protocols
      • Written release not needed…
        • Receiving facility,Transporting agencies
        • Continuation of care
        • 3 rd party billing info
        • Continuing education (remove pt ID)
        • Sate law (rape, abuse, GSW)
        • Subpoena
        • 12VAC5-31-950. Disclosure of patient information.
    • PPCR Falsification Issues
      • Error of omission/commission
        • Document what did/did not happen
        • What steps if any were done to correct it
      • Falsification
        • Revocation of certification
        • Improper pt care due to incorrect assessment
      • Areas of difficulty
        • Vital Signs
          • Document on the ones there were TAKEN
        • Treatments
          • Do not chart procedures there were not performed
    • Pt Refusals
      • COMPETENT adult pt have the right to refuse care at any time
      • Before you leave the scene you should:
        • Try to persuade pt to go to hospital
        • Ensure pt is able to make informed decision
        • Inform pt of why he/she should go & what could happen if he/she does not go
        • Consult med control if need be
        • If pt still refuses
          • Document assessment findings
          • Document any Rx
          • Have pt sign refusal
          • Have a family member, by stander, police sign as witness
        • If pt refuses to sign refusal
          • Have a family member, by stander, police sign as witness
    • Pt Refusals
      • Complete PPCR
        • Complete Pt assessment
        • Care EMT-B wished to provide to pt
        • Statement that the EMT-B explained to pt possible consequences of refusal including death
        • Offer alternative methods of obtaining care
        • State willingness to return
    • Correcting Errors in Documentation
      • Errors made while writing PPCR
        • Draw single horizontal line through error and initial it
        • Write correct info beside line
        • Do not attempt to obliterate the error
      • Errors discovered after report has been written
        • Draw single horizontal line through error
        • Initial and date it
        • Attach a note with the correct info
        • If info was omitted attach a note with date and EMT’s initials
    • Special Situations Mass Casualty Incidents
        • MCI
          • Use of Triage Tags
            • Basic Pt ID data
            • Major Injuries
            • Baseline Vitals
            • Triage Status
        • Local plans have guidelines for MCI
        • When there is not enough time to fill out report before next call:
          • Fill the PPCR out later
    •  
    • Documentation of Death
      • Documentation of Death
        • Withholding treatment if irreversible brain damage can be proven in pt in cardiac arrest
        • Note ALL factors that denote obvious death including/but not limited to :
          • Decapitation
          • Transection of chest and/or abd
          • Rigor mortis
          • Lividity
          • Decomposition
          • Charring of the body
          • Extensive head trauma
          • Chest injury/trauma indicative of mortal injury
          • Other bodily disfigurement indicative of mortal injury
    •  
    •  
    • Special Situations
      • Special Situation Reports
        • Used to document events that should be reported to local authorities or to supplement primary report
          • i.e. Exposure/Injury/Lost property
        • Submitted in timely manner to authority per protocol
        • Accurate and objective
        • EMT-B should keep copy for records
    • Effectiveness of PPRC
        • Accuracy & Honesty
          • State C/C in pt own words
            • “I hurt all over” “Feels like an elephant sitting on my chest”
          • Accurate vital signs
          • Describe your findings NOT conclusions
            • “Pt was found disoriented on the apartment floor with an alcohol-like odor on his breath”
              • NOT
            • “Pt was found drunk on the floor of the apartment”
    • Effectiveness of PPRC Continued
      • Clarity
        • Print legibly
        • Black/blue ink
        • Approved shorthand/abbreviations
        • Correct spelling
        • EXACT location of pain/injury
          • “substernal chest pain”
          • “Puncture wound on anterior chest approx 3 cm off midline”
    • Some Common Abbreviations
      • Female Male
      • a= Before p = After
      • BP= Blood pressure
      • BVM = Bag Valve Mask
      • c= With s= without
      • c/o = complains of
      • CPR
      • DOB = Date of Birth, y/o = Year old
      • Hx = History
      • LLQ = Left Lower Quadrant, LUQ = Left Upper Quadrant
      • NTG = Nitroglycerin
      • O 2 = Oxygen
      • po= By Mouth SL= Sublingual
      • Pt= Patient
      • Px= Physical Exam
      • RLQ= Right lower Quadrant, RUQ = Right Upper Quadrant
      • Tx = Treatment
      • NRB = Non Rebreather NC= Nasal Cannula
    • Effectiveness of PPRC
      • Chronology and Trends
        • Time relationship of :
          • Response- Assessment- Treatment – Transport – Arrival
          • Provides physician with Hx of events
          • Provides trends and responses to treatment
            • i.e. SOB pt c O 2 = Relieved hypoxia – Improved O 2 sats
      • Time Resp Pulse B/P LOC Pupils Skin
      • 16 90 120 A PERRL Cool/Moist/Pale
      • Regular Regular 80
      • 18:10 22 110 110 A PERRL Cool/Moist/Pale
      • Shallow Regular 84
      • 18:15 28 140 90 Voice Dilated Cool/Moist/Pale
      • Shallow Regular 70
      • What trends do you see?
      • What do you think might be causing this???
    • Effectiveness of PPRC
      • Completeness
        • Record all assessment, treatments, reassessments
          • +/- findings
            • “ Pt c/o severe squeezing chest pain on L side but denies radiation”
        • Events that affected treatment/transport
          • Prolonged extrications
        • Role of other providers on scene
        • Treatments provided by lay people
          • CPR, 1 st Aid
        • Other unusual occurrences
          • Belligerent/aggressive pt
        • Removal of items from pt
    • One Last Rule… Document… Document… Document…