Transcript Documentation Presentation

A patient suffers a diabetic emergency. She is treated by the local EMS crew with an
IV, an ampule of D50, and transported to the closet hospital despite family members
telling you that the patient does not go there.
Transport is uneventful and care is turned over to the ED Nurse with a quick verbal
report.
An hour later, a private ambulance is called to transport the patient to her desired
hospital for definitive care. They notice the IV has infiltrated and D50 got into her
surrounding tissues.
The patient suffers significant tissue damage which requires a fasciotomy to
decompress her hand and forearm. She has permanent nerve damage and requires
skin grafting.
Who get invited to the lawsuit party?
Depends on the documentation from everyone involved in
patient care
Documentation
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“If you didn’t write it on your patient care report,
you didn’t do it.”
Objectives
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Importance of Documentation
Identify Data on the PCR
Types of Documentation Formats
Consequences for Poor Documentation
Special Considerations
Grammar and Punctuations
Electronic Reporting and WARDS
Why so Important
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Permanent part of the
patients medical record
Written Proof that you
did something
Written Testimony
Quality Assurance
Operations
Research
“The content and completeness of the prehospital care report directly affects the
lawyer’s impression of the incident and
influences his decision of whether or not
to file a lawsuit.”
Richard A. Lazar, JD
Elements of the PCR
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Date of the Run
Type of call
TIMES
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Received
Enroute
Scene
Patient Contact
Transport
Destination
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Medical History
Allergies
Medications
Chief Complaint
Trauma
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Mechanism
Safety Equipment
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Vital signs
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Blood Pressure
Pulse
Respirations
Lung Sounds
Cap refill
Blood Glucose
Pupils
Organization
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S. O. A. P
C.H.A.R.T
CHRONOLOGICAL
S.O.A.P
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What happened?
What did you find?
What do you think?
What did you do?
(S) (Subjective) What happened?
Medic 27 responded emergent on a 39 year old female
who had a syncope from the standing position. Patient
reports that she was at a party when she began to feel
nauseous. Walked into back room and then passed out on
floor. Witnesses report patient slumped forward on to a
couch and then slid backward to a carpeted floor. Patient
also reports that she recalls waking up on floor,
feeling cold and shivering. Patient moved to bed with
assistance. A bystander called 911 for assistance.
(O) (Objective) What did you find?
Upon initial contact, patient laying in bed in bedroom. Alert
and oriented to name, place, time and event. Skin warm and
dry with normal color and tone. Mild muscle tremors
(shivers) in arms and legs. Patient does report feeling cold.
Head normocephalic without abnormality on visualization
or palpation. Neck midline and intact without pain on
palpation or movement. Thoracic, lumbar and sacral spine
intact without pain on palpation or spontaneous movement.
My Way
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Level of Consciousness
Airway, Breathing, Circulation
Skin color and temp
Head to Toe Exam
Pertinent Negative
(A) Assessment (What do you think?)
Patient transported to Hospital with seizure like activity
Not a diagnosis
Protocol Followed
(P) Plan What did you do?
Patient transported non-emergent to Aurora Medical
Center emergency room. Patient transported without
change in status or level of consciousness. Patients
treatment plan included full secondary assessment,
detailed neurological examination, vital signs, cardiac
monitoring, pulse oximetry and supplemental oxygen.
Following hand off report to staff, patient left in
hospital bed with rails up and staff in attendance.
C. H. A. R. T
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Chief Complaint
History
Allergies
R/x-Treatment
Transport
(C) Chief Complaint
Medic 27 responded emergent on a 39 year old
female who had a syncope from the standing
position.
(H) History Present Illness
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HPI (history of present illness/injury)
PMH (past medical history)
PQRST, AMPLE, MOI,
Onset
Signs and Symptoms
(A) Assessment
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Include both negative and positive findings
Responses the patient has to your assessment such as
the presence or lack of pain and/or the presence or
lack of sensation.
Diagnostic Testing
 ECG
 Pulse Oximetry
 Capnography
 Blood Glucose Monitoring
(R) Rx-Treatment
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Document your treatment
Responses from the Patient to Rx
Changes in Patients condition
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Example “Pain decreased to 5/10 from 7/10 after NTG
administered.
(T) Transport
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Where did you go
Change in condition during transport
Alteration from Protocol
Who did you turn care over to
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(Name if Possible) Ie: RN Robinson
Patency of airway and IV fluids
CHRONOLOGICAL
“Write like your brain thinks it”
Dispatched non-emergent to University Hospitals Emergency
Educations center for a transport to UW ER. Arrived on floor
and met by staff, who advised us that the patient was suffering
from severe PES. (Paramedic Education Syndrome). Patient is
Mr. D, a 48 yo male with hx of PES and CHF, who presented
with chest pain and dyspnea…...
Errors and Falsifications
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Avoid Errors
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Admit when you made a mistake
Revise if necessary
Note date and time of revision
 Keep original document
 Include purpose of the revision
 Only the original author can make the correction
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Errors and Falsifications
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Always be honest and through in your
documentation.
Corrections:
Add a supplement on electronic reports
 One line across the error, initial the mistake and
make the corrections on written reports
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Complete reports as soon as possible.
Lost reports have HUGE legal implications
 Don't keep copies of your reports.
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HIPPA
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What Happens on the
Ambulance stays on the
ambulance.
Health
Insurance
Portability
Privacy
Accountability
HIPPA
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Protects the security and privacy of all medical
records and other health information used or
shared in any form
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Protects patients rights by giving access to
health information and control over how it is
used
PHI Protected Heath Information
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Information that relates to:
 The health of an individual
 Health care provided to that individual
 Payment of heath care provided
What can be shared
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Health Insurance Company my need information to
process a claim
Caregivers involved with direct care
Quality Assurance when necessary
Special Considerations
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Exposure and Injury
Mass Casualty
Interfacility Transports
Refusals
Mass Casualty Events
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Documentation may have to be postponed
Follow Local Policy and Procedure
Comprehensive run report must be completed
for each patient when time permits
Refusal of Care
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Potential for Liability
Good Documentation
Make it clear.
Refusal of Care
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The litigation rate for EMS has been steadily
increasing.
􀁑 According to one study patients evaluated
by paramedics but not transported to the
hospital account for 50 to 90% of EMS
lawsuits”.
􀁑 Documentation is your best defense.”
Documentation:
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Physical Findings.
The advice you give the patient about being transported
and the associated risks for not being transported
Clinical indications that patient is competent to make a
rational decision
Signatures of the patient and witness
Full narrative
Advise to call 911 if condition changes
What not to say:
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Do not at any time attempt to talk the patient out of
going to the hospital.
If you feel strongly that the patient should be seen,
make every attempt to convince them they should be
seen.
Don’t say ‘ I agree you don’t need to go” even if you
agree
A patient suffers a diabetic emergency. She is treated by the local EMS crew with an
IV, an ampule of D50, and transported to the closet hospital despite family members
telling you that the patient does not go there.
Transport is uneventful and care is turned over to the ED Nurse with a quick verbal
report.
An hour later, a private ambulance is called to transport the patient to her desired
hospital for definitive care. They notice the IV has infiltrated and D50 got into her
surrounding tissues.
The patient suffers significant tissue damage which requires a fasciotomy to
decompress her hand and forearm. She has permanent nerve damage and requires
skin grafting.
Initial Transport Agency-CFD
First Receiving Hospital-St Anthony Hospital
Wojcik v. City of Chicago, 702 NE 2d 303 - Ill: Appellate Court, 1st Dist., 2nd Div. 1998
Lets Finish up
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Be Professional
Accurate
Consistent
Through
Clear
Brief
Paint the Picture
Collaborative
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Legible, spelling correct
Tell the Truth
Don’t duplicate info
Follow Protocols
Plain Language
Relevant Information
“The JURY”
Have your partner review