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Pt assess documentation


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Pt assess documentation

  1. 1. Documentation
  2. 2. Topics Principles and Purposes of EMS Documentation Medical Terminology & Abbreviations Roles of Documentation Subjective & Objective Documentation Evaluation of a Finished Document Special Situations
  3. 3. Introduction Your written prehospital care report (PCR) is the only true factual record of events. Your PCR is your sole permanent, complete written record of events during the ambulance call.
  4. 4. Uses for PCR’s Medical Administrative Research Legal
  5. 5. Run data in a PCR helps agencies to improve patient care.
  6. 6. Complete both the narrative andcheck-box sections of every PCR.
  7. 7. General Considerations Use appropriate medical terminology. Use acceptable and approved abbreviations and acronyms. If you do not know how to spell a word, look it up or use another word…
  8. 8. Some systems use check boxes, some use bubble-sheets, and others use electronic documentation
  9. 9. Times Whenever possible, record all times from the same clock. When that is not possible, be sure that all the clocks and watches you use are synchronized.
  10. 10. Communications The communications with the hospital are another important item to document. Document ANY medical advice or orders you receive and the results of implementing that advice and those orders.
  11. 11. Pertinent Negatives Document all findings of your assessment, even those that are normal.
  12. 12. Oral Statements Whenever possible, quote the patient—or other source of information—directly. Example: Bystanders state the patient was “acting bizarre and threatening to jump in front of the next passing car.”
  13. 13. Elements of Good Documentation  Accuracy  Legibility  Timeliness  Absence of alterations  Professionalism
  14. 14. The Proper Way to Correct a Prehospital Care Report
  15. 15. Professionalism Never include slang, biased statements, or irrelevant opinions. Include only objective information. Always write and speak clearly.
  16. 16. 2 Narrative FormatsCHART SOAP  Chief complaint  Subjective  History  Objective  Assessment  Assessment  Rx (treatment)  Plan  Transport
  17. 17. Narrative Writing Subjective part of your narrative comprises any information that you elicit during your patient’s history. Objective part of your narrative usually includes your general impression and any data that you derive through inspection, palpation, auscultation, percussion, and diagnostic testing.
  18. 18. Special Considerations Patient refusals Services not needed Mass casualty incidents
  19. 19. Patient Refusals Patients retain the right to refuse treatment or transportation if they are competent to make that decision. Two main types of refusals:  Person who is not seriously injured and does not want to go to the hospital  The patient refuses even though you feel he needs it.
  20. 20. A patient’s refusal of care requires careful documentation.
  21. 21. One Example of a“Refusal of Care” Form
  22. 22. Services Not Needed Some systems allow paramedics to determine patients that do not require ambulance transportation. While this may help to reduce ambulance utilization, the risks of denying transport are even greater than those of a refusal. Evaluate all patients with even minor injuries and document appropriately.
  23. 23. Mass Casualty Incidents Multiple patients, mass casualties, and disasters all present special documentation problems. Weigh your patient’s needs against the demand for complete documentation. Follow local guidelines and utilize the appropriate forms such as triage tags.
  24. 24. Triage tags are used to record vitalinformation on each patient quickly.
  25. 25. Consequences ofInappropriate Documentation Inappropriate documentation can have both medical and legal consequences.  Do not guess about your patient’s problems.  Write neatly, clearly, and legibly.  Complete your form completely.  Spelling counts!
  26. 26. Summary Principles and Purposes of EMS Documentation Medical Terminology & Abbreviations Roles of Documentation Subjective & Objective Documentation Evaluation of a Finished Document Special Situations