Transcript Documentation - faculty at Chemeketa

Documentation
EMT 170
Emergency Communications and Patient
Transportation
(Cars & Radios)
Documentation – Purpose
• Provides a record of scene information that may
not be available from any other source
• Provides information for the continuity of patient
care from one healthcare provider to another
• Provides a record of specific pre-hospital
interventions performed or attempted
• Provides medical legal evidence
• Reveals any significant changes in the patient’s
condition
• Provides an internal tool for statistics, budgeting,
QA and education
Patient Care Report –
Types of Reports
• Traditional written report
– Typically provides check boxes and a narrative
section
– EMT completes it in written form
• Computer-based report
– Generated on an electronic clipboard or mobile
data terminal
– EMT enters information by special instrument
or keyboard
Written Patient Care Report
(PCR)
Written Patient Care Report
(PCR)
Computer Based Report
System
PCR-Report Elements
• Run data
• Patient data
• Narrative information
Run Data
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Service name
Unit number
Crew license numbers and/or names
Location of call
Response times mileage
Patient Data
• Patient’s name
• Address
• DOB
• Age
• Sex
• MOI/NOI
• Location of
• LOC
• Sensation
• Vital signs
• PMH
• Care provided
• Response to
patient
• Pupillary response
• Assessment
treatment
Narrative
• Used to document
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Patient complaint/history
Observation
Physical assessment finding
Care delivered by EMS crew
Changes in patient condition
• SOAP
General Guidelines
• Collect all patient information
• Complete all blanks and check all
pertinent boxes on call report form
• Do not leave any spaces blank, mark
“N/A” if item does not apply
• Begin narrative by documenting the
patient's LOC
General Guidelines (cont.)
• Attach EKG documentation (where
applicable) with date, time and
patient's name on it
• Sign the report
• Leave a copy of the report with the
patient’s chart
Items to Document
• Patient’s chief complaint using patient’s
own words within quotation marks if
possible
• History of present illness or injury using
OPQRST format
• Physical assessment findings including
pertinent positives and pertinent negatives
• Significant pertinent past medical history
including surgeries, hospitalizations,
illnesses or injuries
Items to Document (cont.)
• Allergies and current medications
• Interventions, who performed them,
time performed, and the patient’s
response or lack of response to
interventions
• Vital signs and times obtained
Writing a Narrative
• Use plain language and medical
terminology
• Avoid slang
• Use only recognized abbreviations
• Spelling general neatness are
imperative to convey professionalism
SOAP Method
S – subjective
– Information the patient tells you
– Patient symptoms
O – objective
– Information the EMT observes about the scene and
possible injuries
A – assessment
– EMTs evaluation of the situation, the patient’s chief
complaint and findings based on the exam
P – plan
– The plan of action and care delivered the EMT
Other Narrative Forms
• Head-to-toe format
• Chronological format
Correcting Mistakes
• Do not erase or mark out a mistake
– Draw a single line through the error and
place initials beside the line
– Add the correct information following
the correction
– If information was initially omitted, add
a note with additional information, the
date, and the EMTs initials
Errors
• DO NOT attempt to cover mistake
• Document what did or did not happen and
what corrective action (if any) was taken
• Falsifying information on a PCR is harmful
to the patient and may lead to the
suspension or revocation of the EMTs
certification and other legal action
Summary
• Documentation is the most important non-clinical
skill possessed by the EMT
• The patient care report must be accurate and
report both subjective and objective findings,
physical assessment results, care and treatment
rendered and any significant observation of the
scene
• The PCR is considered a legal document that
serves as an official record of care given
• The PCR is the EMTs first line of defense if
questions are later raised about the incident