Transcript Documentation

Documentation:
Professionalism, INTEGRITY &
funding
Amy Gutman MD
EMS Medical Director
[email protected]
Who Cares About Documentation?
• CYA!
• Data drives research; research drives outcomes
• CQI & research show you how good your department is, &
highlight room for improvement
• You are professionals – your documentation should reflect this
professionalism
• Not to be bitchy…but poor care (or the perception of poor care)
reflects badly on me. You work under my license & at my
discretion. Don’t piss me off.
But one Chart Doesn’t Change Patient
Care, Does It?
What Did Data Do For SFD?
• Drove change to ETCO2-driven appropriate
ventilation vs “hypo” or “hyper” ventilation
• Proved that EMTs & EMT-Ps apply high level technical &
physiological information to improve cardiac arrest outcomes
• Improved ROSC from 22% to 38% & survival from 4% to 11%
from ALL cardiac arrests in one year
• Changes in Policy:
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Cardiac Arrest
Vehicle & Equipment Sanitation
No Hauls
Death-In-Field
Skills Tracking
Personnel Distribution
What Can Data Do For your fd?
• Justify personnel
• Defend increased number of response vehicles &
transport units
• Show responsibility to the patient, as well as overall
improved quality of care
• Move towards greatness
– Identity strengths & weaknesses
– Document and publish successes
Notebooks
• Every PCR generates 30-50 data points
• Every arrest provides an additional 16 data points
• Missing data weakens patient care, CQI, billing &
research
Charting Methods
• It does not matter which
methods you use, as
long as the
documentation is
thorough, complete &
professional
• Yes…spelling &
punctuation count
DCHARTE & Soap
D
Dispatch Time / Type
S
Subjective
C
CC
O
Observations
H
History
A
Assessment
A
Assessment
P
Plan
R
Rx at Scene
T
Treatment Enroute
E
Exemptions
SAMPLE – OPQRST
O
Onset
S
SSX
P
Provokes
A
Allergies
Q
Quality
M
Meds
R
Radiation
P
PMH
S
Severity
(1-10 scale)
L
Last PO intake
E
Events (i.e. MOI)
T
Time
General Concepts
aKa “Don’t overloaD the truCK”
Key areas of emt liability
• Bad Refusals
– Failure to consider
“competency”
– Failure to document
• Negligence
– Ordinary negligence vs.
Gross negligence
• Abandonment
– Transfer of care
– Failure to document
• Patient Care Issues
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Airway
Spinal Immobilization
Equipment Failure
NV status
NEGLIGENCE elements
• Duty:
– “Obligatory conduct owed by a person to another person.”
– In tort law, duty is a legally sanctioned obligation, the breach of which
results in liability
• Breach:
– “Failure to perform a duty owed to another; a failure to exercise that care
which a reasonable, prudent man would exercise under similar
circumstances.”
• Damages:
– “For actual harm resulting from the defendant’s wrongful act or omission”
• Proximate Cause:
– “Results were caused by one’s conduct or omission.”
Barron’s Law Dictionary, Fifth Edition, 2003
Keep accurate times
•Dispatched to Scene
•Arrival On Scene
•BLS & ALS
•Actions On Scene
•i.e. Medications
•i.e. Time to shock
•Time on Scene
•Departure to Hospital
•Arrival to Hospital
Abbreviations
• No home-grown
abbreviations
–
–
–
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DRT
DFU
BFN
LOL
SPELLING COUNTS
• If a jury looks at a chart
full of basic errors, they
will conclude that you
are as sloppy at patient
care as you are at
documentation
Bystanders & transfers
• Include name, level of training, license number(s) of
ANY medical personnel who have assisted at any
point during assessment or patient care
• Include initials or badge number person writing the
narrative
• When transferring care, document name/ position
who accepts patient
This Is Not CSI
• Unless you’re a medical or forensic specialist
don’t make assumptions
– i.e. Entrance & exit wounds
• Explain what was found & how it appeared
– “Infant was found face-down under her bed-sheets,
cold, mottled, cyanotic, with vomitus noted in
oropharynx”
Charting
Chief Complaint
• Why did patient call 911?
• Pt’s words in quotes
• “Upon arrival found 54 yo F on
couch. Pt reports “feeling like
someone is sitting on my chest.”
» vs
• “Called to house for possible
heart attack”
HPI
• Descriptive narrative telling a story from onset of
symptoms, bystander involvement, prehospital
treatments to time of transfer
History Obtained from someone
other than patient
• Indicate why
– Language barrier
– Disability
• Document who provided history
– Translator
– Family
– Friend
PMH/ PSH
• Past Medical & Surgical
– Medical / surgical
– Similar presentations: “The last time my chest hurt this
much, I went to the cath lab”
• Allergies
– Drug & reaction
• Medications
– Write “BP med” if that is what pt states
– Be as thorough as possible
gooD emts aren’t helPeD
By bad Documentation
SAD BUT TRUE EXAMPLES
• “Arrived on scene, pt sick to her stomack, said she
ate some food that may be bad. V/S normal. Placed
pt in POC and transported to ER.”
• “On scene found patient drunk. He’s a regular who
always gets drunk. He called for EMS to avoid going
to jail. He stinks bad. We turned him over to PO.”
• “Caled 4 medcal raisins. Patience in floore. She wus
sikk. She puuked on floore. Blud wus in the puok.
She didn’t waunt us so we lift.”
Vitals are vital
• Complete Vitals:
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BP
RR (effort / number)
O2 sat / capnography
HR
Temperature
• Repeat serially
• Note changes in pt status
– If you do something…what
happened?
Dispatch
• Computer Aided Dispatch
– Best Friend vs Worst Enemy
– Only as good as the dispatchers
& dispatch tools
• Nature & Type of call
• Updates Enroute
– CPR in progress
– Police on scene
MVC HPI
HPI should emphasize mechanism of injury
What Is missing from above HPI?
MVC HPI
•
Types of vehicles involved
•
Principal Direction of Force
(PDOF)
•
Speed of both vehicles
•
Description of Damage/ Intrusion
•
Number of Patients
•
Position of Patients
•
Death/ Serious Injury in
Passenger
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Restraints
•
Ambulatory at Scene
Trauma HPI
Assessment
• Your “impression” rather
than a diagnosis
• Observations & subjective
information
• “51 yo M with CP & ST
elevations in II, III, AvF”
• “Provider Impression”
– Essential for billing
– Proof that pt had an ALS
assessment & treatment
Treatment
• All interventions
• Includes:
– Bystander interventions
prior to your arrival
– Your interventions
– Any positive or negative
response to treatment
• “Pt placed on 100%
NRB. Sat increased from
88 to 97%, RR decreased
from 34 to 18/min”
Examples of “Treatments/ Interventions”
Other Treatments & Interventions
Transportation & triage
• Methods of transfer to unit & to hospital
- Seated
- Supine
- C spine immobilization
• Any treatment initiated or continued while en-route
– “VS reassessed q 15mins
– O2 at 10 LPM NRB due to decreased O2 sat from 99% RA to 90% RA”
Transportation & triage
• Document name & title of the person to which
patient care was transferred
• Reason for Triage:
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Closest facility
Trauma Triage
Patient request
If “Requesting” & “Transport” hospitals are different,
document why
Exceptions TO STANDARD OF CARE
• All treatments must be consistent
with OEMS protocols
• Document everything that was
done
– If a standard treatment was not done,
why not?
– Any “exception” from norm, i.e. “Patient
refused ASA due to known allergy”
• CYA - Justifies why you did or did
not do something
• Keeps CQI & Medical Director off
your back
Trauma Patients
• Trauma triage legislation
requires providers to
document if pt met criteria
for transportation to a
trauma center
• Try to justify using at least 2
criteria:
– “Pt unconscious following
front-impact MVC.
Transported to a Level 1
trauma center due to
bilateral femur fractures.”
Refusals
• NEVER from pediatrics, or intoxicated/ confused adults
• Thoroughly document effort to provide informed consent
including potential complications (use & write the word “death”)
• All refusals must be signed, including signatures by the patient/
guardian/ power of attorney, provider & witness
– If police or family not available, your partner’s signature is adequate
• Refusals are the most common prehospital documents to show
up in court – pay extra attention to spelling, grammar,
punctuation, signatures, times & dates
DNRs / MOLST
• Patient can change mind at any time
– “Patient requested EMS to disregard DNR”
• Include statement regarding DNR in PCR
– Date document signed & who signed it
• If the paperwork is not physically present it does not exist
Cardiac arrest
documentation
• Reportable to state & national registries
• Affects policy, national standards & patient
outcomes
Utstein CA Data Collection
• Date / Time
• Incident Number
• Accepting Hospital
• Age / DOB
• Gender / Race
• Past Medical History
• Down Time
• Initial & Serial Rhythms
• Initial & Serial Vitals
• Ventilation rate
• Initial & Serial ETCO2
• Time to Patient Contact
• Any Interventions (meds,
defibrillation)
• Time On Scene
• ROSC
• Witnessed Arrest
• HPI Narrative
• Bystander CPR
BASICS
XXXXX
xx
xx
John Smith
111-11-1111
Good
Narratives tell
“Stories”
•Should have “4 Point” intubation confirmation in narrative
•ETT visualized passing through cords
•ETCO2 confirmation
•BL breath sounds ausculated
•No epigastric sounds
Sloppy & Incomplete
This patient SURVIVED a cardiac arrest…wouldn’t it have been
nice to know why?
Time to Patient Contact
•NOT time “on scene”
•If BLS unit arrived first, document their interventions
•Time on scene also important to document; national
standards are <10 mins
Witnessed Arrest & Bystander CPR
• “Yes” or “No”
• Was AED was used on scene?
• Important for tracking community involvement & outcomes
• May help in receiving public health grants for education
Vitals are VITAL!
• If patient has no vitals or spontaneous respirations, document:
– Rate at which you are ventilating patient
– ETCO2
– Rate you are performing chest compressions
• New CPR Guidelines & ongoing research into the “best”
resuscitation strategies
• ETCO2 is not just a number, it may be a predictor of outcome
Rhythm
• Initial
• Changes with any intervention
• Final rhythm at presentation to ED
FYI
• NV status before & after splinting & spinal immobilization
• Loose/ missing teeth prior to intubation
• Subjective “feelings” are assessments
• Protect patient confidentiality
• Falsification of EMS reports equals fraud
• Spelling, grammar & punctuation count – this is a legal
document and reflects your professionalism
PUNCTUATION IS POWERFUL!
• An English professor wrote these words on a
chalkboard and asked his students to punctuate it
correctly:
• “A woman without her man is nothing”
• All of the males in the class wrote:
• “A woman, without her man, is nothing”
• All of the females in the class wrote:
• “A woman: without her, man is nothing”
Thanks For The Great Job You Do
Everyday!
Any Questions? [email protected]