Transcript Emscharts Training P..

Lanoka Harbor Emergency Medical Services
Lanoka Harbor Emergency Medical Services
After logging in, click on “Patient Records” in left navigation column
Lanoka Harbor Emergency Medical Services
Click on “Create blank chart” button
Lanoka Harbor Emergency Medical Services
Page 1: Dispatch Information
Each box will be covered independently in the following slides
Lanoka Harbor Emergency Medical Services
The “General” Box
Basesite will always remain “Squad 26 Lanoka
Harbor EMS”
Unit will change to whichever vehicle you are in.
You will only have to change the “BLS” option if
you are in a first response vehicle, in which case
you would select “First Responder”
Select the appropriate shift
For “normal” calls the “Response” section will
remain with the default entry of “Emergency”, but
may need to change according to call
demographics
“Type of Svc. [Service]” will be either “Scene” for
call in our primary coverage area, or “Mutual Aid”
for call in Lacey First Aid’s area.
“Category” and “Dispatched As” are pretty much
self explanatory, although they may differ on the
same call
“Outcome” is where you will select how the patient
was transported to the hospital. Items of note:
-SNN= Services not needed.
-Cancelled Prox= Too far away
“Vehc. Grid” and “Dispatch
LOC” are where the apparatus
Is
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COMING FROM!
The “Referring” Box
All calls are dispatched to the Referring Address.
For our purposes, the “Other” button will always
be selected
In the “Other Type” dropdown box, you will select
the referring type, such as residence, doctor’s
office, etc.
You then must click the magnifying glass next to
the “Location” box. From here you will see a new
screen pop up with the ability to enter an address.
To enter, start typing in the “Common” box. Finally,
erase the entry in the “Location Name” box,
leaving the numerics and street name in the box
below. The zip code and county fields will
automatically populate with the correct information
The “Requester” is the person who initiated the
911 response system. If this is unknown, you may
simply enter “911”
“Scene Grid” is the town in which the referring
address is located
The “Ref. GPS” field will be automatically
populated
“Mode” is how you responded to
the referring address
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The “Crew Members” Box
You will select the members who were on the
truck in this area. If the words “please select”
appear next to a crew member name, click on
them. In the next popup window, select the
appropriate certification level. (Drivers and Cadets
will select “First Resp”) After selecting, click on
“Use NJ”
If you combine crews with another EMS agency,
you may put their name in the “Other” field
Lanoka Harbor Emergency Medical Services
The “Receiving” Box
For all hospital transports, you will leave the
“Hosp” button checked
Select the hospital you transported to in the
“Name” field
The “Unit” will generally stay “Emergency
Department.” Other possibilities include “Trauma
Unit” or “Delivery Room”
Mode is how you responded to the receiving
facility
“Dest. Basis” is why you transported to the above
referenced facility. Options include “Patient
Choice” “Closest Facility” among others
“Dest. Grid” is what town/city the receiving faility is
located in
The “Dest. GPS” field will be automatically
populated
Comments are not required
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The “Times” Box
Clicking on “Edit Times” on the first page will bring up the
screen to the left.
The first thing you will do in this area is clear all fields up to
“Dispatched”
Dispatch= Time call went out
EnRoute= Time the unit left to go to the referring address
On Scene= Time the unit arrived at the referring address
At Pt= Time the crew made contact with the patient
Dep Ref= Time ambulance left to go to receiving facility
Arv Rec= Time ambulance got to receiving facility
Xfer Care= Time the crew transferred care to facility staff
Cancelled= Time the unit gets cancelled from a job
Available= Time the unit cleared scene/ receiving facility
In Qtrs= Time the unit was back at squad building
The “First Resp” field may remain empty, or filled in with the
on scene time of a first response vehicle
Lanoka Harbor Emergency Medical Services
For all charts, the user will click on “Add Patient >>”- even if there is no patient.
Lanoka Harbor Emergency Medical Services
For a standby or other event where there was no patient contact made, you would select
“No Patient” Otherwise, click on “Search for Existing Patient”
Note: If “No Patient” skip the next three slides
Lanoka Harbor Emergency Medical Services
On this screen you will enter as must patient information as possible. After entering the
information, click on “Search”
If your patient has been treated before by our organization, there name will be present,
and you may click on their name. If this is a new patient, click “Add new Patient”
Lanoka Harbor Emergency Medical Services
If you have an existing patient, the next screen will automatically populate. In this case you would want to double
check with the patient that his/her medications/allergies have not changed, and that he/she has not developed a
new medical condition.
If you have a new patient, you will have to enter these demographics manually. You should also note that if the
patient lives at the referring address entered on page one, you may click on the blue arrow to import the referring
address to save time. Adding PMHX, Medications and Allergies will be covered on next slide.
Lanoka Harbor Emergency Medical Services
There is a precise order needed to select a medical condition, medication or
allergy.
First you must start typing the name of item you wish to add. Second you will notice items start to pop up as you
are typing. Click on the appropriate item. At this point you must go to the top right corner of the picklist and click
“Add” If you do not click “Add” your data will not be saved. After clicking “Add” you will notice the “Selected” field
becomes blank again. You may now continue to enter values as required, continuing to hit “Add” after each input.
When you are finished, you must click “Done” Again your data will not be saved unless you follow this process.
When this has been completed for “PMHX” “Current Medications” and “Current Allergies” you may click next.
Lanoka Harbor Emergency Medical Services
Page 2: Patient chief complaint, history of illness and patient movement
Each box will be covered independently in the following slides
Lanoka Harbor Emergency Medical Services
The “Impression / Diagnosis” Box
The top three fields are optional. That being said, we still would like you to fill out as much as possible.
The “Condition At Dest” field is mandatory. You will be required to select the patient’s condition upon arrival at the receiving facility.
Options include: Improved, Unchanged, Worse, Dead
System
Symptoms
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Impression
The “Chief Complaint” and “Secondary Complaint” Boxes
This is where you will enter the patient’s chief complaint
If the patient is complaining of multiple ailments, place the secondary complaint here
Lanoka Harbor Emergency Medical Services
The “History of Present Illness” Box
This field is where you enter you narrative will be entered. After your input, you may click the “ABC” button to check your spelling
Lanoka Harbor Emergency Medical Services
The “Reason for Encounter” and “Drugs/ Alcohol” Fields
Here you will select the reason you have
encountered this patient. If a medical
issue (as opposed to traumatic) you would
select “Non-Injury”
Here you will select whether or not there was a suspected substance abuse issue. If you select anything
other than “None” in this field, a data new field will appear with possible indicators. Select all that apply.
Lanoka Harbor Emergency Medical Services
The “Scene Description” Box
In the “Scene Description” box you will describe what you saw. Also, you will note if the scene was safe, and
if any police officers were on scene. If you are authoring a first responder chart, your narrative would be
entered in this box.
By selecting the picklist next to the “Other EMS” field, you will be able to select any other EMS
units on scene with you. This includes, but is not limited to, other squad 26 units, squad 23 units, and
MONOC medic units.
The “Other Agencies” picklist will allow you to select non-EMS units on scene. If you indicated
in the “Scene Description” box that there were police officers on scene, be sure to indicate that in this field
as well.
Lanoka Harbor Emergency Medical Services
The “Patient Belongings” Box
In this field, be sure to write
ANYTHING that was brought from the referring address to the receiving facility.
Lanoka Harbor Emergency Medical Services
The “Patient Movement” Box
As you will note, there are three drop down boxes contained in the “Patient Movement” box. All options are pretty
much self explanatory. Please note that if a patient is in the normal reclined position on the stretcher, select “SemiFowlers”
If you are authoring a first responder chart with no patient, you will have to select “Not Applicable” in all boxes.
Lanoka Harbor Emergency Medical Services
The “Forms Received / Delivered” Box
Be sure to check both sets (“From Ref.” and “To Rec.”) of any applicable boxes in this field
Lanoka Harbor Emergency Medical Services
The “Factors Affecting Care” Box
In this box you will be able to select factors that impacted trip or turnaround times. Each area will be covered in depth
on the following slides.
Lanoka Harbor Emergency Medical Services
The “Factors Affecting Care” Box
Dispatch Factors
Response Factors
Factors continued on next slide >>
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Scene Factors
The “Factors Affecting Care” Box
Transport Factors
Turn-Around Factors
If there were no delaying factors, you may click the “Set All Factors to None” Button. After completing the
“Factors Affecting Care” Box you may click “Next Page >>”
Lanoka Harbor Emergency Medical Services
Page 3: Neurologic and Airway Assessment
Each box will be covered independently in the following slides
Lanoka Harbor Emergency Medical Services
The “Neuro” “Airway” and “Initial Glasgow Coma Score” Boxes
Page 3 charting shall be done on an exception only basis. If all areas in the “Neuro” “Airway” and ”Initial Glasgow
Coma Score” boxes are normal, you may click “Defaults” in the bottom left corner. After completing this page you
may click “Next Page >>”
Lanoka Harbor Emergency Medical Services
Page 4: Respiratory and Cardiovascular Assessment
Each box will be covered independently in the following slides
Lanoka Harbor Emergency Medical Services
The “Respiratory” and “Cardiovascular” Boxes
Page 4 charting shall be done on an exception only basis. If all areas in the “Respiratory” and ”Cardiovascular”
boxes are normal, you may click “Defaults” in the bottom left corner. After completing this page you
may click “Next Page >>”
Lanoka Harbor Emergency Medical Services
Page 5: Secondary Survey
Page 5 charting shall be done on an exception only basis. If all areas of secondary external examination
are normal, you may click “Defaults” in the bottom left corner
Lanoka Harbor Emergency Medical Services
If there is an abnormality noted, mouse over the affected area, and click. Check any box(es) that are
applicable. Be sure to click save after each area of the body, or your data will not be saved. After
completing this page you may click “Next Page >>”
Lanoka Harbor Emergency Medical Services
Page 6: Labs and Fluids
&
Page 7: Medications and IV’s
Page six and seven are not required, and not able to be filled out, as they are not within
the BLS scope of practice
Lanoka Harbor Emergency Medical Services
Page 8: Secondary Survey
On page 8 you will enter your patient’s vital signs. Important reference times will be noted across the top of the
screen. The “Protocol” drop down box is optional, and does not require you to make a selection. It is very
Important to remember to hit “Save / Add Line” as your data will not be saved until you click. Once all vital signs
have been documented, you may click “Next Page >>”
Lanoka Harbor Emergency Medical Services
Page 9: Miscellaneous Forms
Each box will be covered independently in the following slides
Lanoka Harbor Emergency Medical Services
The “Miscellaneous Forms” Box
You are required to complete
a follow up letter on each
patient care report. Mouse
over “Followup Letter” and
click. Be sure not to click
inside the “Print” box.
For all charts where a patient
was transported, select
“Chief’s Letter” from the
“Template” field. If there was
no transport (RMA, DOA,
First Responder chart) you
may click “Letter not required”
in the bottom right corner. You
may also choose this option
based on your judgment, i.e.
if a patient coded during
transport, or you are aware of
obvious financial difficulties. If
“Letter not required” is clicked
a new window will pop up
asking for a reason. Please
note you may have to
allow popups for this
step to be completed.
Lanoka Harbor Emergency Medical Services
The “Attached Files” Box
You may attach files as required to your patient care reports. Acceptable
files include a sketch of an accident scene, or paper RMA scan. If you need
to attach a file you would simply click the “Attached Files” button and the
screen below will open. From there you will be able to select the file to be
uploaded and the file category. After all fields have been completed, click
“Upload” You will then have to manually navigate back to page nine to
complete your chart.
Lanoka Harbor Emergency Medical Services
The “Signatures” Box
All patient care reports are required to be signed by an
EMT. To do so, click “Sign Chart”
After the “Electronic Signature” box pops up, enter your
password and SSN/Pin in their respective fields and click
“Save Signature”
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The “Print Chart” Box
Some receiving facilities afford EMS agencies the ability to print their patient care reports as they enter the emergency
room. If you desire you may print your chart and/or any attached forms by clicking any of the “Chart” “Forms” or “Chart &
Forms” buttons
Lanoka Harbor Emergency Medical Services
The “Quality Assurance” Box
After completing your patient care report click on “Complete / Lock Chart” If all
fields are complete you will have successfully entered a call. If there have
been any mistakes, a new screen will open with said mistake(s) listed. You
may click on each mistake to be taken to that page of the patient care report.
After fixing any mistakes, you may manually return to page nine, utilizing the
navigation bar on the left side of your screen. You will notice a window that
asks you to confirm the locking of the chart. Click “OK” on this screen and the
next, and your chart input is complete.
Lanoka Harbor Emergency Medical Services
If you have any questions or concerns, please see any Operations Officer for
assistance.
Lanoka Harbor Emergency Medical Services