5)Documentation

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5)Documentation

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

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