Transcript Power Point - eastern area prehospital services dispatch

EASTERN AREA PREHOSPITAL
SERVICES
QA / CQI
DOCUMENTATION TRAINING
INTRODUCTION
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EAPS Documentation Standards
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State / Command Documentation
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Trip Log vs Trip Sheet
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What to include
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What not to include
INTRODUCTION
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Why we document
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Good Documentation Practices
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Legal Aspect of Documentation
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Examples
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Closing and Questions
EAPS has specific documentation standards.
Many that are very different than other EMS
agencies.
Our billing and admin staff try to be on top of all
new insurance requirements and we adapt our
documentation accordingly.
Page 1 - Dispatch
Page one is pretty self explanatory.
Make sure your crew assignments are correct and
you have listed the correct shift. Anyone shown in
the activity log preforming a procedure must be
listed as crew.
Patient Information
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Get as much demographic information as you
can.
EAPS requires an estimated weight for all
patient contacts.
Signatures are required for all patient contacts.
If you get a refusal the consent/privacy form
should also be signed.
Patient Information
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Make every effort to secure billing information
on every transport and patients that receive
treatments. Even refusals that receive treatment
of any type.
If you can get this now, we will have it for future
calls.
PAGE 2
This is one of the most important pages for
including information for our billing department,
and can be the deciding factor as to whether we
get paid for the call.
This is also the best page for you to provide your
“picture” of the call and initial contact.
Page 2
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You MUST select and impression
Initial patient acuity shows what level of
seriousness the patient presented with.
CHIEF COMPLAINT
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This should not be what you was dispatched to.
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This should be why the person called 911
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You should type what the patient states or
portrays as the reason they need to go to the
hospital.
CHIEF COMPLAINT
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SICK is not a complaint. Nausea, vomiting,
fever, trouble breathing. The symptons of the
patient's illness are good chief complaints.
Motor Vehicle Crash is not a chief complaint.
Neck pain post MVC. Head pain. Back pain. All
of these are why that patient needs an
ambulance and ultimately, transport.
HISTORY OF PRESENT ILLNESS
This area is the most crucial. The information
provided in this small block is the primary
information used by insurance to authorize the
payment for our treatment and transport.
HPI
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At EAPS we have a few requirements for HPI.
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Every HPI should start with the statement
“Eastern Area Medic 312 responded
immediately for a 911 dispatch. E0
Dispatch Code for a female unconscious.
Arrived on scene to find 57yo female
complaining of weakness.”
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Every call that a medic is on and patient
contact is made, MUST include the
statement “ALS Assesment by
Paramedic __________”
HPI
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Your HPI is the one place to start to draw that
verbal picture of your call.
You should include all pertinent details of your
patient's condition, complaint, situation, events
leading to, pertinent negatives, etc...
Your treatment and activities preformed on the
call do not belong in the HPI. Concider the HPI
as what happen till I arrived.
Other EMS
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This is where you put other agencies or trucks
that responded with you. Even if you list them
as crew, if they came in a different truck, include
that information here.
If QRS responds they must be added in this
section.
If mutual aide companies respond they must be
included.
PAGE 3 Neuro/Airway
This is a first impression or what is reported to you
. This should not reflect the patient's assessment
at his/her best or worse. This should not include
airway management done by your crew. Only
procedures preformed prior to your crews arrival.
Page 4
Same as page 3. This page is first impression.
Only document oxygen if it was on the patient
when you arrived. Home oxygen or oxygen the
facility / staff / QRS put on the patient prior to you
arriving.
Page 5
As the page implies this is a reasonable place to
document your assessment.
You should document all findings, as well as all
pertinent negatives in your assessment.
Page 6
Again this is for IVs, Medications dilivered, and
drips that were given/initiated prior to you
beginning care.
DO NOT DOCUMENT YOUR TREATMENTS IN
THIS SECTION.
Page 8 – Activity Log
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This section should include all activities that you
and your crew preformed or took part in.
This is also where you will document all
qualifying documentation for meds, treatments,
and care.
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Changes in patient condition.
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Observations.
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Anything that took part during your contact with
the patient should be documented here.
Page 9
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Activity audit is required to close the tripsheet.
You MUST scan and attach all pertinent
documentation for the call.
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Run Sheet
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Billing sheet with signature
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Medical Necessity
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Refusal
You must sign your chart.
Once this is complete. I recomemd clicking “Entire
Chart” view and go over your tripsheet before
advancing it.
Make sure you have completed all required sections.
Provided all the information you needed or wanted
to.
For serious or involved calls we recommend that
another member of the crew review the tripsheet
before saving it.
We do not kick charts back for changes. You will
have to make an addemndum to the chart for any
corrections.