Chapter 016[1]

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Chapter 016[1]

  1. 1. Chapter 16 DocumentationCopyright © 2007, 2005 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 1
  2. 2. Overview Minimum Data Set The Prehospital Care Report  Functions of the Prehospital Care Report  Traditional Format  Other Formats  Distribution  Documentation of Patient Care Errors  Correction of Documentation Errors Documentation of Patient Refusal Special Situations  Multiple-Casualty Incidents  Special Situation Reports Copyright © 2007, 2005 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 2
  3. 3. Minimum Data Set Patient information gathered at time of EMT- Basic’s initial contact with patient on arrival at scene, following all interventions, and on arrival at facility  Chief complaint  Level of consciousness (AVPU)—mental status  Systolic blood pressure for patients older than 3 years  Skin perfusion (capillary refill) for patients younger than 6 years  Skin color and temperature  Pulse rate  Respiratory rate and effort Copyright © 2007, 2005 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 3
  4. 4. Minimum Data Set Administrative information  Time incident reported  Time unit notified  Time of arrival at patient  Time unit left scene  Time of arrival at destination  Time of transfer of care  Accurate and synchronous clocks Copyright © 2007, 2005 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 4
  5. 5. Prehospital Care Report Functions of the prehospital care report  Continuity of care • A form that is not read immediately in the emergency department may very well be referred to later for important information Copyright © 2007, 2005 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 5
  6. 6. Prehospital Care Report Functions of the prehospital care report  Legal document • A good report has documented what emergency medical care was provided and the status of the patient on arrival at the scene and any changes on arrival at the receiving facility • The person who completed the form ordinarily must go to court with the form • Information should include objective and subjective information and be clear Copyright © 2007, 2005 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 6
  7. 7. Prehospital Care Report Functions of the prehospital care report  Educational • Used to demonstrate proper documentation and how to handle unusual or uncommon cases Copyright © 2007, 2005 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 7
  8. 8. Prehospital Care Report Functions of the prehospital care report  Administrative • Billing • Service statistics • Research • Evaluation and continuous quality improvement Copyright © 2007, 2005 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 8
  9. 9. Traditional Format Traditional written form with check boxes and a section for narrative Copyright © 2007, 2005 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 9
  10. 10. Traditional Format Sections  Run data • Date, times, service, unit, names of crew Copyright © 2007, 2005 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 10
  11. 11. Traditional Format Sections  Patient data • Patient name • Location of patient • Address • Treatment administered prior to arrival • Date of birth • Signs and symptoms • Insurance information • Care administered • Sex • Baseline vital signs • Age • SAMPLE history • Nature of call • Changes in condition • Mechanism of injury Copyright © 2007, 2005 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 11
  12. 12. Traditional Format Sections  Check boxes • Be sure to fill in the box completely • Avoid stray marks Copyright © 2007, 2005 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 12
  13. 13. Traditional Format Sections  Narrative section (if applicable) • Describe, don’t conclude  Include pertinent negatives  Record important observations about the scene ( e.g., suicide note, weapon)  Avoid radio codes  Use abbreviations only if they are standard  When information of a sensitive nature is documented, note the source of that information (e.g., communicable diseases)  Be sure to spell words correctly, especially medical words  For every reassessment, record time and findings Copyright © 2007, 2005 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 13
  14. 14. Patient Care Reports Confidentiality  The form itself and the information on the form are considered confidential Copyright © 2007, 2005 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 14
  15. 15. Patient Care Reports Distribution  Local and state protocol and procedures will determine where the different copies of the form should be distributed Copyright © 2007, 2005 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 15
  16. 16. Documentation of Patient Care When an error of omission or commission occurs, the EMT-Basic should not try to cover it up Instead, document what did or did not happen and what steps were taken (if any) to correct the situation Copyright © 2007, 2005 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 16
  17. 17. Documentation of Patient Care Falsification of information on the prehospital care report may lead to suspension or revocation of the EMT-Basic’s certification/license Poor patient care may result because other health care providers have a false impression of which assessment findings were discovered or what treatment was given Copyright © 2007, 2005 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 17
  18. 18. Documentation of Patient Care Specific areas of difficulty  Vital signs—document only the vital signs that were actually taken  Treatment—if a treatment like oxygen was overlooked, do not chart that the patient was given oxygen Copyright © 2007, 2005 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 18
  19. 19. Correction of Documentation Errors discovered while the report form is being written  Draw a single horizontal line through the error, initial it, and write the correct information beside it  Do not try to obliterate the error—this may be interpreted as an attempt to cover up a mistake Copyright © 2007, 2005 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 19
  20. 20. Correction of Documentation Errors discovered after the report form is submitted  Preferably in a different color ink, draw a single line through the error, initial and date it, and add a note with the correct information  If information was omitted, add a note with the correct information, the date, and the EMT-Basic’s initials Copyright © 2007, 2005 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 20
  21. 21. Correction of DocumentationCopyright © 2007, 2005 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 21
  22. 22. Documentation of Patient Refusal Competent adult patients have the right to refuse treatment Copyright © 2007, 2005 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 22
  23. 23. Documentation of Refusal Try to persuade the patient to go to a hospital Ensure the patient is able to make a rational, informed decision Inform the patient why he or she should go and what may happen to him if he does not Consult medical direction Copyright © 2007, 2005 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 23
  24. 24. Documentation of Refusal Document any assessment findings and emergency medical care given, then have the patient sign a refusal form Have a family member, police officer, or bystander sign the form as a witness Copyright © 2007, 2005 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 24
  25. 25. Documentation of Refusal If the patient refuses to sign the refusal form, have a family member, police officer, or bystander sign the form verifying that the patient refused to sign Copyright © 2007, 2005 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 25
  26. 26. Documentation of Patient Refusal Complete the prehospital care report  Complete patient assessment  Care EMT-Basic wished to provide for the patient  Statement that the EMT-Basic explained to the patient the possible consequences of failure to accept care, including potential death  Offer alternative methods of gaining care  State willingness to return Copyright © 2007, 2005 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 26
  27. 27. Documentation of Patient Refusal Copyright © 2007, 2005 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 27
  28. 28. Special Situations Multiple-casualty incidents When there is not enough time to complete the form before the next call, the EMT-Basic will need to fill out the report later Copyright © 2007, 2005 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 28
  29. 29. Special Situations The local MCI plan should have some means of recording important medical information temporarily (e.g., triage tag) that can be used later to complete the form The standard for completing the form in an MCI is not the same as for a typical call The local plan should have guidelines Copyright © 2007, 2005 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 29
  30. 30. Special Situation Reports Used to document events that should be reported to local authorities or to amplify and supplement primary report Should be submitted in timely manner Should be accurate and objective The EMT-Basic should keep a copy for his own records The report, and copies, if appropriate, should be submitted to the authority described by local protocol Copyright © 2007, 2005 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 30
  31. 31. Special Situation Reports Examples of incidents requiring special reports  Exposure  Injury  Equipment failure  Ambulance crash Copyright © 2007, 2005 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 31
  32. 32. Continuous Quality Improvement Information gathered from the prehospital care report can be used to analyze various aspects of the EMS system This information can then be used to improve different components of the system and prevent problems from occurring Copyright © 2007, 2005 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 32
  33. 33. Summary Minimum Data Set The Prehospital Care Report  Functions of the Prehospital Care Report  Traditional Format  Other Formats  Distribution  Documentation of Patient Care Errors  Correction of Documentation Errors Documentation of Patient Refusal Special Situations  Multiple-Casualty Incidents  Special Situation Reports Copyright © 2007, 2005 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 33

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