Transcript File - indydovesems

Documentation and
Communication
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Opening
Case
Documentation
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Warm up your
pens.
Perry is
having chest
pain.
Perry is
50 years old
He has a history of
angina and has
experienced heart
attacks in the past.
He is a fairly stalwart
individual and does
not like to ask for
help.
My chest
really hurts. It
feels like I
have an
elephant
standing on
it. I just can’t
catch my
breath.
Perry
Perry discretely shows
you a bottle of
sildenafil he
borrowed from a
friend.
He admits his
discomfort started
after lunch, during
some strenuous
physical activity. He
won’t elaborate.
I took two of
my
nitroglycerin
tablets, but it
just won’t go
away.
I also have a
bad
headache.
Perry
Perry has no allergies.
He smokes three
packs of cigarettes a
day.
His wife is traveling
today, but he has a
cell phone contact
for her and he would
like you to call her.
This pain is
about a “9”
on a scale
from 0 to 10.
It goes into
my shoulder,
too.
I didn’t black
out or vomit.
Narrative
Write down a history of the
present illness for Perry.
Sick or Not-yet-sick?
SICK?
or
NOT YET SICK?
Why?
Once upon a
time…..
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Introduction
Two sections to this lesson:
• Written
documentation
• Verbal reports
Introduction
Critical Skills
As important as
other skills in the
profession
Documentation
• Factual evidence
• Core principle of
professionalism and
accountability
• Must not be governed
by a “minimum
standard”
Documentation
• Should reflect high
levels of
professionalism
worthy of respect
• Proper documentation
process creates a
protective, legally
defensible report
Documentation
• Write prehospital
reports with the jury in
mind
• Your PCR should not
be a legal handicap—
it should be your legal
shield
Street Secret
A working ballpoint pen
with black ink is an
essential piece of
equipment for a
paramedic
– Carry a few extra and a
small notepad in your
pocket
Foundation of Documentation
• Pertinent scene size-up information
• The assessment
• Medical history
• Vital signs
Foundation of Documentation
• Physical examination
• Treatment provided
• Continued assessments
Specific Expectations
• Agency requirements
• Jurisdictional considerations
• State obligations
• HIPAA (Health Information Portability
Accountability Act)
Professional
Accountability
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Professionalism
• Documentation is an
extension of your
professionalism.
• Judged by
– Language
– Tone
– Grammar
– Spelling
PCRs
• Clinicians,
physicians, nurses,
social workers, and
other allied health
professionals all
have access to your
PCRs
PCRs
• Nonclinical personnel who have access to
your PCRs:
– Billing agents
– Insurance auditors
– Federal investigators and law enforcement
– Risk managers
– EMS administrators
– Attorneys
– Expert witnesses
Documentation Is Evidence
• Judged reliable and truthful
• Recorded contemporaneously
• Credible written testimony
Documentation Is
Evidence
• Factual credibility is
enhanced when it is:
–
–
–
–
–
–
Timely
Concise
Accurate
Organized
Properly punctuated
Correctly spelled
Street Secret
Be professional:
– spelling,
– diction, and
– grammar…
make all the
difference.
Poor Documentation
May implicate you in certain
circumstances revealing
–Omission of required treatments
–Violations of protocol
–Lack of vital and supportive
documentation
What’s wrong with this form?
Errors
A misteak mistake
should be crossed
out and initialed.
Well-Written
Reports
• Compel the reader to
appreciate your decisionmaking
• Provide rationale supporting
the protocol and treatment plan
you followed
• Include imagery involving the
senses
What is the purpose of including the
imagery of sight, touch, smell, and feel in
documentation?
A. To show that the patient’s neurological system is
intact
B. To convey an accurate picture of events
C. To promote professionalism through language
D. To show that it was written and it was done
What is the purpose of including the
imagery of sight, touch, smell, and feel in
documentation?
A. To show that the patient’s neurological system is
intact
B. To convey an accurate picture of events
C. To promote professionalism through language
D. To show that it was written and it was done
Hallmarks of
a Well-Written
PCR
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Hallmarks of a WellWritten PCR
•
•
•
•
•
Factual
Well-formatted
Accurate
Succinct
Organized
Hallmarks of a Well-Written PCR
•
Respect for the prehospital provider’s
accountability for proper documentation
–
Not simply with regard to the patient
Organizational Framework
Poor organization =
Poor impression =
Poor care provided
Organizational Framework
Good organization =
Thorough assessment/treatment =
Good care provided
(and is defensible)
Narratives
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Narratives
• Traditional narratives can be fragmented
and a collection of disjointed facts
Narratives
Two commonplace frameworks:
•CHART
•SOAP
(or SOAPIER)
Standardized Content
• ALL NARRATIVES MUST CONTAIN:
– Age
– Gender
– Conditions
– Chief complaint
– Associated complains
– Relevant past medical history
– Medications and allergies
Standardized Content
• ALL NARRATIVES MUST CONTAIN:
– Assessment findings
– Treatment
– Responses
– Reassessments
– Transportation/disposition of the patient
Objective Information
• Objective notations are observed
– Observable clinical signs
– Physiologic data
– Technology-derived data
– Descriptive observations
– Measurable comparatives
Subjective Information
• Subjective information can
be remembered as spoken:
– Feelings
– Opinions
– Use only subjective
information collected
– Use quotes as needed
Why is objective information important?
A. It includes the patient’s medications
B. It’s factual and recorded by a trained
observer
C. A third party reports the information
D. It describes events leading to the 9-1-1 call
Why is objective information important?
A. It includes the patient’s medications
B. It’s factual and recorded by a trained
observer
C. A third party reports the information
D. It describes events leading to the 9-1-1 call
Street Secret
• Document
assessments
from head to toe
CHART
Format
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CHART FORMAT
C = Chief complaint
H = History
A = Assessment
R = Treatment
T = Transfer/transport
• C = “Chief complaint”
of the patient or the
reason EMS was
summoned
CHART Framework
• H = History. Symptoms:
•
•
•
•
•
•
O: Onset
P: Provocation or Palliation
Q: Quality
R: Region or Radiation
S: Severity
T: Time
CHART Framework
CHART Framework
• H = History (SAMPLE):
•
•
•
•
S: Signs/Symptoms
A: Allergies
M: Medications
P: Past and pertinent
medical history
• L: Last oral intake
• E: Event leading up to the
injury or illness
CHART Framework
• A: = (Physical) Assessment using the:
– Head-to-toe approach
– System-by-system approach
– Primary and secondary assessment approach
• R = Rx (Treatment)
– Following a protocol template
– Detailed listing of the treatment in
accordance with the accepted protocol
– Evaluation or response to each element
of treatment
CHART Framework
• T = Transport and Transfer (Utilizing TTFN)
–
–
–
–
To
Time
Fluids
Necessary status update
CHART Framework
SOAPIER
Format
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SOAPIER Framework
S
= Subjective information: “chief
complaint” and patient history
SOAPIER Framework
S = Symptoms (use OPQRST mnemonic):
•
•
•
•
•
•
O: Onset
P: Provocation and Palliation
Q: Quality
R: Region or Radiation
S: Severity
T: Time
SOAPIER Framework
– S: Symptoms (using OPQRST)
– A: Allergies
– M: Medications
– P: Past medical history
– L: Last oral intake
– E: Event leading to injury/illness
SOAPIER Framework
O
= Objective information:
• Physical exam
– Head-to-toe approach
– System-by-system approach
– Primary and secondary assessment approach
SOAPIER Framework
A/P
= Analysis or Assessment/
Plan or Protocol to be used
– Differential diagnosis,
– Field impression, or
– Working diagnosis
SOAPIER Framework
I/E
= Implementation of Protocol/
Evaluation of treatment
• Chronological listing
SOAPIER Framework
R
•
•
•
•
= Report
To: who received the patient and at what facility
Time: of transfer of care to the receiving facility
Fluids: type and volume of any fluids infused
Necessary status update: on the patient condition
A structured narrative format will:
A.
B.
C.
D.
Save you from documentation errors
Provide accurate billing
Show you are a professional
Assist in keeping information organized and
thorough
A structured narrative format will:
A.
B.
C.
D.
Save you from documentation errors
Provide accurate billing
Show you are a professional
Assist in keeping information organized and
thorough
Avoiding Biased Information
• Considered prejudicial information
• Preconceived judgments or opinions
• Negative bias may lend itself to a
complaint of libel
Pertinent
Negatives
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What is a
pertinent negative?
Absence
of an expected sign or symptom:
•Patient denies chest pain
•No loss of consciousness
Recording Pertinent Negatives
• Critical nonfindings
– Absence of chest pain during a cardiac event
– Absence of jugular venous distention
– Absence of tachycardia in a patient with
hypovolemia
• Provides evidence that a history was
performed
Opening Statement
• Sets the scene for the reader
–Who
–Where
–What
–Why
–When
Content Issues
Legible
– Illegible handwriting may be construed as
substandard hands-on patient care
– Multipage forms require firm pressure
Black or blue ink
Diction refers to the use of:
A. Proper word choice
B. Words that are spelled the same but have
different meanings
C. Words that are spelled the same forward and
backward
D. Redundant terms
Diction refers to the use of:
A. Proper word choice
B. Words that are spelled the same but have
different meanings
C. Words that are spelled the same forward and
backward
D. Redundant terms
Diction
• Diction
– Make sure to use the proper words; pay
special attention to homonyms
• their, there, and they’re
• right, rite, and write
• to, too, and two
– Slang terminology must be avoided
Street
Secret
“The
patience
were found
on the rode
and said
the crash
happened
write in the
middle of
rush our.”
Punctuation
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Punctuation
• Promotes focus of the
word picture
Punctuation Promotes Focus of
the Word Picture
• Comma: used to separate items
• Quotation marks: mark the beginning and
end of a direct quotation, certain titles,
and words
• Hyphens: used to divide words
Punctuation Promotes Focus of
the Word Picture
• Apostrophe: shows possession and forms
word contractions
• Colon: used to indicate that a block of
information or a series of ideas follows
• Parentheses: used to enclose an
explanation or qualification
Timeliness
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Timeliness
• The call is not complete until the patient
care report is complete
• Follow local and state requirements
Other Pertinent Times
• The time the call was
received
• The time your unit
was dispatched
• En route time
• Arrival time
• Contact time
Street Secret
Document patient contact time
• If your response was three minutes, that
looks good. But if you then need to climb
eighteen flights of stairs and walk down a
very long corridor before you get to the
patient, it may look as though your first set
of assessments was not timely.
TIME; it is all about TIME
TIME STAMP
PATIENT
CONTACT
- Turn on ECG monitor when you reach your patient’s side
Other Pertinent
Times
• The time your unit left
the scene
• Arrival time at
receiving facility
• Return-to-service time
Other Pertinent
Times
• Medication
administration
• Vital signs
• Specific procedures,
like beginning CPR,
initiating a medication
drip, or pronouncing
death
Street Secret
• Call the dispatcher at the beginning of
your shift and synchronize your watch with
the dispatcher’s time.
• Cell phones and other devices that are
updated via radio/satellite signal will give
you exact times.
Accuracy
• This includes any
mistakes or omissions
in treatment as well
• Show adherence to
the standard of care
Accuracy
• Be specific in listing treatments
• Don’t substitute “critical care” for the
procedures that fall under that category
• Documentation inconsistencies can cause
significant difficulties in a court case
Precise vs.
Concise
• If using computerized documentation and the
“drop down” boxes or specified “fields” for
information doesn’t have what you’re looking for,
BE SURE to use the narrative to supplement your
documentation
•
•
•
•
Proofread the report.
Have your crew members proofread the report?
Are there spelling errors?
Is the punctuation correct?
Evaluation Checklist
• Does the run sheet factually reflect the patient
encounter?
• Does the report require any supplemental
forms?
Evaluation Checklist
Different
Forms
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Patient Care Forms
• Example of a
PCR with more
narrative space
Maine State EMS form
Patient Care Forms
• Example of PCR
with more check
boxes
MidAmerica EMS
Patient Care Forms
Trifold PCR from Iceland (compact)
Scannable into a computer database
Illinois State EMS form
Abbreviations
and Jargon
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When is use of jargon appropriate?
A.
B.
C.
D.
When trying to avoid HIPAA violations
To save space on a patient care report
To communicate quickly with other EMS staff
To express yourself colorfully with acronyms
When is use of jargon appropriate?
A.
B.
C.
D.
When trying to avoid HIPAA violations
To save space on a patient care report
To communicate quickly with other EMS staff
To express yourself colorfully with acronyms
Jargon
• Used to communicate quickly among
members of the profession
• Works well in verbal communication
• Can be detrimental in written accounts
Using nonstandard acronyms…
A. Is useful to explain odd events for which an
existing acronym is not available
B. Helps your partner document quickly
C. Is acceptable during verbal reports
D. Is not acceptable in prehospital documentation
Using nonstandard acronyms…
A. Is useful to explain odd events for which an
existing acronym is not available
B. Helps your partner document quickly
C. Is acceptable during verbal reports
D. Is not acceptable in prehospital documentation
Abbreviations and Symbols
• Save time
• Must be used in the proper context
R
S
True or False
The Department of Transportation
(DOT) releases an annual “Do
Not Use” list that contains a list of
abbreviations that should be
avoided.
A. TRUE
B. FALSE
True or False
The Department of Transportation
(DOT) releases an annual “Do
Not Use” list that contains a list of
abbreviations that should be
avoided.
A. TRUE
B. FALSE
Abbreviations and Symbols
• Save time
• Must be used in the proper context
• Should not be on the JCAHO “Do Not
Use” List
JCAHO Do-Not-Use Examples
MS can mean morphine sulfate or
magnesium sulfate or multiple sclerosis
CC is mistaken for “U” units when
poorly written. Use mL (or milliliters)
Documentation
of Refusals
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Informed
Refusal
Thoroughly document:
- Legal capacity
- Mental capacity
- Adequate
information for
decision-making
Legal Capacity
• Legal age
• Emancipated minor
• Legal guardian
Mental Capacity
•
•
•
•
•
Hemodynamic instability
Physical and emotional trauma
Hypoxia
Illness/Injury
Chemical influence
Informed consent refusal
requires you to document:
A. Past medical history
B. A statement that the patient was not
injured severely to the best of your
knowledge
C. Influence of family members in the
refusal
D. A statement that risks were explained
and transportation was offered
Informed consent refusal requires you to
document:
A. Past medical history
B. A statement that the patient was not
injured severely to the best of your
knowledge
C. Influence of family members in the
refusal
D. A statement that risks were
explained and transportation was
offered
Informed Refusal
•
Adequate information for decision
making should include:
–
–
–
–
Offer of services
Disclosure of the risks and benefits
Offer of transportation
Risks or consequences of the refusal
Communicating the Risks
• Use language the patient understands
• Do not speak in medical terminology
• Have the patient state back to you his or
her understanding
Documentation
• Obtain the patient’s signature
• A witness’s signature is merely an
acknowledgment that the patient actually signed
the document
Street Secret
Direct patient–MD
contact can help:
- Convince the
patient to go
- Document the
refusal on a
recorded phone
line
Witness
Signatures
You should obtain:
–
–
–
–
Legibly printed name
Relationship to the patient
If law enforcement, unit or badge number
Contact information (phone, employment, or
location)
Cancellation of Services
• Document the canceling authority
• Time of the formal cancellation
• If a patient contact was made,
complete an informed refusal report
Radio
Reports
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The Radio Report
(Consultation with Online Medical Direction)
• Name of unit calling
and your name
• Obtain the physician’s
name and/or number
if orders are issued
The Radio Report
(Consultation with Online Medical Direction)
• Remember to:
– Speak clearly
– Be concise
– Request
specific
meds/orders
– Repeat orders
back to confirm
The Radio Report
(Consultation with Online Medical Direction)
INCLUDE
•
•
•
•
ETA to the receiving facility
Age, sex, and weight of the patient
Level of consciousness
A concise description of the patient
The Radio Report
(Consultation with Online Medical Direction)
INCLUDE
•
•
•
•
Level of distress
A brief history and physical
Vital signs and treatments provided
Ask the physician if they have any
questions
Verbal
Reports
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Verbal Report to
Receiving Facility
• Description of the chief complaint
• SAMPLE history, vital signs, and physical
examination findings
• Information of any treatments
Verbal Report to
Receiving Facility
• Time of administration of any medications
• Time when any critical events occurred
Verbal Report to
Receiving Facility
• Turn over any medical records and HIPAA
compliance documents
• Turn over any patient effects that are in your
custody
Dispatch and Scene
Size-Up
• Medic 11: Priority one; a fall
at the Salamander Race
Track; your patient is in the
first aid room
Patient Contact
• Janice approached a
security guard and stated
she had fallen and hit her
head
• She was taken to the first aid
room by wheelchair
• Security is stabilizing her
head
Primary Survey
Alert 48-year-old female
• A: Patent
• B: Nonlabored
• C: Strong radial pulses
Janice speaks:
• I slipped and fell on a wet
floor. I fell down five cement
steps. My head hurts.
• Please write down that
Salamander’s floor was wet
and that there wasn’t a “wet
floor” sign in front of the water
spill.
Janice answers you:
My neck doesn’t hurt or
anything. Is this all really
necessary?
They should have had a
sign.
No, I don’t have any back
pain or breathing troubles.
No, I did not pass out.
Janice answers you:
I ate nachos at the
concession stand.
I don’t have any medical
problems. I do take Zoloft,
but who wants to know
that?
I’m allergic to penicillin.
Physical Exam
Vital Signs are:
BP: 130/90
P: 84 regular
R: 12 nonlabored
SaO2: 99% on
room air
Your partner says:
Lungs are clear in all fields,
There is no deformity to her
neck or back. PERL. No
nystagmus.
Moves all extremities and
has intact circulation, motor
function, and sensory
function.
Physical
• HEENT: Clear of fluids, PERL, no JVD,
trachea midline;
• CHEST: CEBBS; = rise; no retractions;
• ABD/PELVIS: Soft nontender; stable;
• EXTREM: MAE well; CMS intact x4;
• Vitals: BP 130/90; P 84 R; R 12 NL; SpO2 99% RA
Field Impression?
Treatment/Transport
You applied a C-collar.
Janice insisted on transferring
herself from the wheelchair to
the long spine board and
refused to be lifted. “I’m too
heavy,” she said.
You finished immobilizing her with
a long spine board and
transport her to the hospital of
her choice.
En Route
Janice
complains:
-My back hurts.
-I don’t think you
put this collar on
right. My chin
hurts.
Conclusion
• After a short stay at the emergency
department and a full set of x-rays, the
patient was discharged with a diagnosis of
a possible concussion.
Lawsuits
• Janice later sued:
– Salamander Race Park for not having a “wet
floor” sign and settled out of court for $10,000.
– Your ambulance service, for improperly
immobilizing her spine, resulting in long-term
back pain from a lumbar subluxation
(diagnosed by her chiropractor, a former EMT
who testified as an expert witness at the trial).
She won $1,000,000 for pain and suffering
from your ambulance service.
What’s a Girl
to Do?
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Summary
Documentation must:
– Be well-written
– Be all-inclusive
– Promote a professional stance
Summary
• Documentation is a
critical skill
• Serves as a testimonial
to your professionalism
• Reflects your adherence
to the standard of care
and accepted protocol
Summary
It should be
– organized,
– legible,
– factual,
– accurate, and
– timely
Summary
• Verbal reports
should be
– organized and
– concise
• Radio
consultations
should be brief
And we will all live
happily ever after.
The End.
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