Transcript Medical-Legal and Documentation

Medical-Legal and
Documentation
Condell EMS System CE
September 2009 CE
Prepared by Debbie Semenek, RN, EMT-P
Objectives
Upon successful completion of this module, the
EMS provider will be able to:
1. Identify the principles of EMS
documentation
2. Discuss the confidential nature of the
patient care report
3. Identify the potential consequences of illegible,
incomplete, or inaccurate documentation
continued
4. Identify the special documentation
considerations concerning patient refusals,
restraints, minors, and the behavioral emergencies
5. Identify the purpose of the CMC EMS System
Request for Clarification, the EMS Incident
Report, and the After Action Report
6. State the components of a valid State of Illinois
advanced directive form
7. Complete all areas of the Patient Care Report at
the completion of the class
The Patient
Care Report
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Is the first medical record – creates a baseline
Is a legal document
An operational record
Used for research
Administrative tool
Does your documentation reflect the care you
gave to your patient?
Confidentiality
• The law prohibits the release of medical or
other personal information about a patient
unless:
– The patient consents to the release
– Other medical care providers have a need to
know
– Is required by law (subpoena)
– Need for third party billing
HIPAA
• Health Insurance Portability and Accountability Act
• This act enhances the confidentiality of medical
records and mandates that EMS personnel be
educated as to the requirements of the law.
• What do I need to know to do my job?
• Do you know your departments procedure?
Report Writing
• Provides a step-by-step account of the care
you provided
• Record of time sequence
• Reflects your professionalism
• Document exactly what you did, when you
did it and the effects of your interventions
The Report
• A well written, thorough PCR suggests a
thorough, efficient assessment and quality
care.
• A sloppy, incomplete PCR suggests sloppy,
inefficient care.
Special Documentation
Considerations
• Patient Refusals are high risk and overused. Must
include documentation of the patient’s state of
mind. Must be an informed refusal.
• Explain why care is necessary. Inform the patient
of the risks of refusal and document your attempts
to do so.
• Any questionable, confusing, and/or complex
refusal should be called in to Medical Control and
documented while on scene.
Refusals
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Have the patient sign the release
statement which applies.There should
be 2 witnesses to the release form. One
should be the provider assigned to the
ambulance and the other should be
preferably a family member or
bystander (e.g. police officer, etc.).
Include witness addresses when
possible.
Refusals cont’d
• Any patient who refuses to sign the refusal
form should have this witnessed and signed
by a family member, bystander, or police
officer, if possible.
• If permission for release is gained over the
phone (ie: from the parent), document “phone
permission” and write in the parent’s name
• Perform complete assessments on your
patient.
Refusals
• There must be detailed, written documentation
that the patient appears mentally capable to refuse
treatment and/or transportation. Complete
documentation of the patients mental capacity
includes a description of the patient’s orientation
to time, place and person.
• Perform complete assessments on all patients
including vital signs.
• When obtaining a release on a diabetic call,
document the last blood sugar indicating a value
over 60 and the patient’s current mental status
Restraints
• At times, the use of restraints may be necessary to
protect the patient from harming themselves or
others.
• Document the behavior that the patient was
exhibiting that led you to the conclusion that
restraints were necessary.
• Handcuffs are to be applied by Police Officers
only. The police officer must accompany the
victim/patient in the ambulance while being
transported when wearing handcuffs.
Minors
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In Illinois, any person under the age of 18 is considered
a minor, unless legally emancipated, e.g. pregnant, a
married male/female. If the minor’s parent is less than 18
years of age, the parent can give consent for their child.
Once a minor delivers, if they remain in the parental
role, they remain emancipated regardless of living
arrangements
Minors cannot refuse transport, unless emancipated.
If a minor patient refuses to cooperate,remember that in
questions of competency to grant or refuse treatment, a
person who legally is not competent to grant consent is
also not legally competent to refuse consent.
Behavioral Emergencies
• Competent emotionally disturbed
individuals have the same right to refuse
treatment and transportation by EMS as
other individuals.
• EMS should consider underlying problems
and past history of the patient. Consider
hypoxia, hypotension, trauma, etc.
Behavioral continued
• Documentation must include a description of the
patient’s orientation to person, place and time.
• Put statements in quotes.
• Document patient’s behavior.
• If ETOH/Drugs are suspected, document what the
pt. tells you they ingested (in quotes). Describe
any behavior the pt is exhibiting. Document the
presence of liquor bottles, pills, etc.
Petition for Involuntary Admission
• Most of these forms will be completed by
hospital staff
– These forms cannot contain hearsay information
– If you heard the patient make threats of harm,
then you would be involved in completing the
form – especially if in the ED the patient denies
making threats
• Transport to the closest ED unless patient
makes a request or has a previous relationship
Involuntary Admissions
• Transport psychiatric patients to the closest
ED
– NOT okay to by-pass a hospital to take the
patient to a facility with a psych ward
• The ward may not have available bed space
• The patient may need to be cleared
medically prior to admission
• Just because there is a psych ward in that
particular facility does not mean that patient
would be admitted there
Involuntary Admission Forms
• To complete these forms:
– Use “quotation marks”
– Be objective
– Can list others’ observations but state who gave
you the information and list that person under
“witness”
• Note: without detailed information, the
courts must often release the subject
– Need facts to back up the allegations
Request for Clarification
• May be used by any System participant.
• The purpose of this form is to request an
explanation (or clarification) of a specific
situation such as: apparent deviation from
the SOP’S, questionable orders, or any
misunderstanding between hospital and
provider personnel related to policy,
procedure, equipment, a specific run.
Incident Reporting
• An incident is an occurrence, which is not
consistent with the routine operation of
prehospital care, or the routine prehospital
care of a patient.
• The Incident Report Form is to be used for
problems which are more serious in nature.
• Do not document on the PCR that the
incident form was completed.
The PCR – Patient Care Report
• Is about the patient!
• Complete all areas
• Sections that do not apply should be marked not
applicable (N/A)
• Sections that apply but were not assessed,such as
blood pressure, should be marked D/N/A (did not
assess).
• Sections that cannot be completed because the
information is unknown should be marked UNK
(unknown)
PCR
• All times should be recorded using the 24hour clock.Midnight should be entered as
0000.
• Chief Complaint- is the complaint as stated
by the patient, or in the case of an
unconscious patient, the initial dispatch
complaint.
– Example “trouble breathing”
PCR
• Initial Impression-is your initial impression
of the patient’s condition. It should match
the treatment approach or protocol
followed.
– Example: “Pulmonary edema”
• GCS-should be calculated on all patients
and should reflect the level of
responsiveness documented under “status”
box.
Vital Signs
• For the stable patient, readings should be taken
approximately every 15 minutes or more
frequently.
• For the unstable patient, readings should be taken
every 5 minutes or more frequently.
• Drugs-Record all medications given. Note the
time, drug/solution, dose and route of
administration.
• For IV fluids, include the size of the bag hung, IV
catheter size and site.
PCR
• Cardiac monitor-Rhythm interpretation is
considered part of vital signs. If you run a 12 lead
EKG, check or “x” the box provided. Include a
copy of the strip/ekg with the medical record and
for the EMS staff. Record your interpretation.
• Crew signatures-the person completing the PCR
should sign on the #1 line. Print names of other
crew members in the remaining spaces.
• Crew member System ID numbers are added after
each name.
• Paramedic students add “PS” after their name
Documentation Tips
• Use correct grammar and spelling
• Correct errors by putting a single line thru
the error, write the correct information
beside it and initial the change.
• Stay away from “appears” or “seems”
• Document changes and responses to those
changes.
• Document each time the patient is assessed.
Documentation
• Document pertinent negatives
• Document why you deviated from normal
practice.
• Does your treatment fit the observed
medical condition?
• Continuation forms are available if you
need more room to write.
• Always include assessment of o,p,q,r,s and t
PCR
• Always document delays in response.
(Scene/transport activity that interfered with
delivering care to the patient- train, weather,
traffic).
• Document everything you do.
• Your name is on the PCR, do you know what it
says? Is the information accurate?
– Crew members should read over what is written
before the PCR is turned over to hospital staff
• Only use approved abbreviations (CMC list).
Limit use of abbreviations.
• If it’s not written down, you didn’t do it!
When should a PCR be written?
• Generate a patient care report each time you
make contact with a patient. Having this
document will never hurt you unless poorly
completed.
• Abandonment is the termination of the
EMT/Paramedic –patient relationship
without providing for the appropriate
continuation of care while it is still needed
and desired by the patient.
Transfer of Care
• You cannot turn the care of a patient over to
personnel who have less training than you
without creating potential liability for an
abandonment action.
• EMS Scene Transfer- If another unit/
department initiates patient care, obtain a
report from them.
Suspected Abuse and Neglect
• EMS are mandated reporters for child/elder
abuse /neglect (to DCFS and Abuse Hot
Line).
– Forms in the Paramedic rooms at the hospitals
• Document findings objectively. Use quotes
when indicated.
• Relay all info to the receiving facility.
• The receiving facility must also report the
incident to DCFS & Abuse Hot Line.
Medical Control
• Medical direction can only be provided by a
licensed hospital. Acute care /Immediate
care centers cannot give EMS orders. If you
respond to a Acute Care Center, contact
medical control in the usual manner.
• You can only transport patients with
medication drips infusing that are in the
SOP’s (ie: lidocaine, dopamine).
Region X Patient Management
Plan
REMINDER:
• Complete the Field Provider Log Form and
the After-Action Report
– Can be completed by anyone on the call
– Can be done individually or as a group
effort
• Fax both forms to the EMS Office of the
Resource Hospital immediately following
the incident
REGION X
MULTIPLE PATIENT MANAGEMENT PLAN
FIELD PROVIDER LOG FORM
Your Name:
Contact Phone #:
Date: ________________________ Time: _______________________
Fire Department: _______________
Hospital you are contacting: ___________________________________
ED Phone #:___________________
CLASS 1: “Business as usual”
CLASS 2 or CLASS 3
Field personnel call the closest appropriate hospital
Field personnel call their Resource Hospital for Transportation Management
“Hello. This is the __________________________
“Hello. This is the __________________________
Fire Department. We are on the scene of a Class 1
Fire Department. We are on the scene of a Class __
multiple patient incident. The incident is a
__________________________________________
multiple patient incident. The incident is a
(describe the event to the ECRN).
Our total number of patients is ________________.
__________________________________________
We have: (fill in the specific numbers of patients)
Our estimated number of patients is ___________.
_____
Category I Trauma
_____ Category I Medical
_____
Category II Trauma
_____ Category II Medical
_____
Category III Trauma
_____ Category III Medical
How many patients can you take?” ____________
If patients will be transported to other hospitals report those destinations to the
ECRN and record below. NO MORE THAN TWO PATIENTS MAY BE
SENT TO HOSPITALS WITHOUT PRIOR APPROVAL FROM THE
RECEIVING HOSPITAL.
Hospital:
Hospital:
Hospital:
Hospital:
Complete table
with specific
hospital name(s),
#’s and patient
acuities.
Cat I Trauma
Cat II Trauma
(describe the event to the ECRN).
We estimate that we have the following types of
patients:
RED: _____
YELLOW: _____
GREEN: ______
DECEASED: _____
Our closest hospitals are:”
(IMPORTANT: List in order of proximity to the incident)
1. ________________________________________
2. ________________________________________
3. ________________________________________
4. ________________________________________
Cat III Trauma
5. ________________________________________
Cat I Medical
“MY CALL BACK TELEPHONE
NUMBER IS”: _________________
Cat II Medical
Cat III Medical
TOTALS
*Use SMART® Command Board to record hospital
availability and patient destinations.
NOTE:
1)
2)
NOTE:
1)
2)
Complete an After-Action Report (critique form)
Fax both this form and the After-Action Report to the EMS Office
of the Resource Hospital IMMEDIATELY following the incident.
Complete an After-Action Report (critique form)
Fax both this form and the After-Action Report the EMS Office of
the Resource Hospital IMMEDIATELY following the incident.
REGION X
Name:
FD or Hosp:
MULTIPLE PATIENT MANAGEMENT PLAN
AFTER-ACTION REPORT
Date of Incident: ________ Time of Incident: ________ Primary Fire/Rescue Agency: ___________________
Description of Incident: ______________________________________________________________________
Check One:
CLASS 1 
: Total # patients: ____ (Specific # Trauma: Cat I___ Cat II___ Cat III___ Medical: Cat I___ Cat II ___ Cat III ___)
/
CLASS 2 
CLASS 3 
: Total # patients: _____ (Specific #: Red _____ Yellow _____ Green _____ Deceased _____)
Please answer the following questions. Use the reverse side for additional comments (take note when faxing form).
Which hospital was first contacted by field personnel?______________________________________________
Mode of communication between field and hospital: Cell phone Telemetry MERCI Other:_______
Any difficulties with initial communication? No  Yes:__________________________________________
Was it difficult to determine the ‘Class’ of the incident? No
 Yes:________________________________
Any difficulties with triage? No  Yes:_______________________________________________________
Receiving Hospitals / # pts to each hospital: ______________________________________________________
 Yes:___________________________________________
Any difficulties with ambulance to hospital communication (Class 1 only): No  Yes:_________________
Was the two-sided Multiple Patient Management Plan REFERENCE CARD used? Yes No 
If yes, was it helpful? Yes No Comments: _________________________________________
Was a Region X Multiple Patient Management Plan LOG FORM used? Yes No 
If yes, was it helpful? Yes No Comments: _________________________________________
Any difficulties with patient disbursement? No
Overall, how effective was Region X Multiple Patient Management Plan in successfully disbursing patients from the scene to
area-wide hospitals?
Very Effective 
Effective 
Ineffective

Very
Ineffective 
The success of the plan depends on your detailed comments. Please provide us with any additional information that may be
helpful:
_________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Hospital Personnel – Submit this form and Emergency Department Log form to your hospital EMS Coordinator.
Field Personnel – Fax this form and Field Provider Log Form to the Resource Hospital EMS Office.
Advanced Directives
• Components of a valid DNR order
– Must be a written document which has
not been revoked
• Living wills may not be honored by
EMS
Advanced Directives cont’d
– Advanced Directive contains the
following:
• Name of patient, name and signature of
the attending physician, effective date,
the words “Do Not Resuscitate: and
evidence of consent – either signature
of the patient, or the patient’s legal
guardian, or signature of power of
attorney for health care agent or,
signature of surrogate decision maker
How can we improve?
• Clearly document what you found when
you arrived.
• Document a thorough patient assessment
(include pertinent negatives)
• Make sure your treatment goes with your
impression.
• Your treatment should demonstrate that you
know and follow your SOP’s.
Improvement continued
• Document responses to treatment.
• Document patient condition on arrival at the
receiving facility
• Take time to consider what you are
documenting
• Get input from others on the call
• Be objective- avoid personal opinions
Case Reviews
• Now, lets review some PCR’S…. And
remember that it’s easy to find faults in
documentation. If you follow basic
documentation principles the faults won’t
be there and won’t be yours!
• To view the run reports, contact your
department’s educational liaison.
PCR
• Remember- the PCR becomes a part of the
permanent medical record- many people
will see and review your documentation!
PCR Discussion #1
• Is legible- all areas are completed
• No abdominal assessment noted, initial
impression- trauma to abdomen
• Ten weeks pregnant-ask about discharge,
cramping (pertinent negatives)
• No witness on the refusal
PCR Discussion #2
• Is legible- but watch spelling – ie: seizures
• What is routine medical care? IV, O2,
Monitor? or IV, O2, blood glucose?
• “3 minutes after Morphine given”…
– Was morphine given? If so, why? Was there a
med error? Any evidence of substance abuse?
• GCS info sloppy / hard to interpret
• Drugs- add 0 before .9% = 0.9%
PCR Discussion #3
• Chief complaint-what did the pt tell you?or
what were you called to?
• Initial impression-seizure?
• “Since Sunday”, when was Sunday?
• How was patient worse?
• IV-size of bag, site of catheter?
• Moved to MICU? RMC?
PCR Discussion #4
• History – does it say
“several” neck ops?
• When was Friday?
• Abdominal
assessment?
• IV- size bag, site of
catheter, size of
catheter
• Pain 8/10 & 8/10what did you do to
relieve pain?
• Heart rate-156- Are
you thinking about
why his rate is that
elevated?
PCR Discussion #5
• Initial time is blank
• How was error
• How did pt “improve”?
corrected?
• Are heart rate and resp • Avoid “RMC”
rate normal for this 7
• Use pertinent
year old?
negatives here- no
• Are side effects from
retractions, no nasal
the meds given?
flaring, or use of
• On scene time 20
abdominal muscles.
minutes- is that too
long?
PCR Discussion #6
• DOA• Watch spelling (“stomic”, “fowl”)
• Correcting the spelling error – one line through the
word but needs to write “error” and place your
initial
• “No obvious signs of fowl play”? Is that a police
responsibility?
• Good documentation of the scene and how patient
was found
PCR Discussion #7
• Initial impression (reflects the SOP to follow)“Face pain” from what? Motor Vehicle Crash?
• What category trauma is the patient?
• Description of injuries indicate potential
head/neck injury- patient not collared and
boarded.
• Choking on blood- what could have been done for
that?
• IV- what type of fluid?
PCR Discussion #8
• Did pt fall? Dispatched for a “fall” but this
mechanism of injury was not clarified/addressed
• Watch “RMC” abbreviation
• Was second IO successful? Did pt receive any IV
fluid volume?
• Vitals taken every 5 minutes? Repeat pulse ox?
• Any suspicion of substance abuse, alcohol?
• Pain 8/10 & 8/10-where was the pain?
PCR Discussion #9
• What was the time of onset?
• MVC- immobilization provided?
– Was this patient reliable?
• If pt is disoriented, do you believe her when she
says she has no pain?
• No times on vitals or meds
• Lung sounds? Why was lasix given?
• Was 12 lead performed? Not checked on PCR
• How much aspirin?
• Long on scene time – any reason given?
PCR #9 continued
• A cardiac alert was called for this patient for
suspicious ST elevation (negative on further
evaluation)
• This patient did have a combination of
issues: a low blood sugar and MVC.
• This is an example of tunnel vision- lost
sight that this patient was also involved in a
motor vehicle crash.
PCR Discussion #10
• Narrative indicates problems with staff at
nursing home - This info should be placed
on an incident report - not on the PCR.
• Description of seizure activity?
• Lengthy on scene time?
• What type of “stare”?
• Suctioned patient? Was there an
obstruction?
Alteration of the original PCR
• What do you do if you realize that you
omitted something from your report?
– Complete a continuation sheet and write in
“addendum”
– Do not back date the addendum; add date and
time the addendum was completed referring to
the original report
– Forward the report to the respective facility the
patient was transported to
Remember that the original report and copies
must match!