Chapter 14 Documentation
U.S. Objectives U.S. Objectives are covered and/or supported by the PowerPoint Slide Program and Notes for Emergency Care, 11th Ed. Please see the Chapter 14 correlation below. *KNOWLEDGE AND ATTITUDE 3-8.1 Explain the components of the written report and list the information that should be included in the written report. Slides 11-22 3-8.2 Identify the various sections of the written report. Slides 8-9, 16-22 3-8.3 Describe what information is required in each section of the prehospital care report and how it should be entered. Slides 8-9, 16-22 3-8.4 Define the special considerations concerning patient refusal. Slides 28-30 3-8.5 Describe the legal implications associated with the written report. Slides 5-6, 23-28 3-8.6 Discuss all state and/or local record and reporting requirements. Slides 34-35 3-8.7 Explain the rationale for patient care documentation. Slides 5-6 (cont.)
U.S. Objectives *KNOWLEDGE AND ATTITUDE 3-8.8 Explain the rationale for the EMS system gathering data. Slides 6-7, 15, 17 3-8.9 Explain the rationale for using medical terminology correctly. Slide 22 3-8.10 Explain the rationale for using an accurate and synchronous clock so that information can be used in trending. Slide 17 (cont.)
U.S. Objectives *SKILLS 3-8.11 Complete a prehospital care report.
The Prehospital Care Report (PCR)
Prehospital Care Report Functions: Continuity of care Legal document Quality improvement (cont.)
Prehospital Care Report Functions: Education Billing information Statistics Research
Prehospital Care Report (Handwritten)
Prehospital Care Report (Computerized)
Pen-Based Computer and PDA
PCR Data Set Each piece of information is an element (i.e., vital signs). U.S. defines minimum elements for a PCR.
Minimum Data Patient Information Gathered at the time of the EMT s initial contact with patient on arrival at scene, following all interventions, and on arrival at facility (cont.)
Minimum Data Patient information: Chief complaint Level of consciousness (AVPU), mental status Systolic BP for patients more than 3 years of age
Patient Information Skin perfusion (capillary refill) for patients less than 6 years of age Skin color and temperature Pulse rate Respiratory rate and effort
Administrative Information Time of incident report Time unit notified Time of arrival at patient Time unit left scene Time of arrival at destination Time of transfer of care
Data Sections of the PCR
Run Data
Patient Data
Treatment Given
Narrative (cont.)
Narrative Avoid conclusions be objective. Include observations of the scene. Include pertinent negatives. (cont.)
Narrative Avoid slang and radio codes. Use only standard abbreviations. Use correct spelling. Write legibly.
Prehospital Care Report Confidentiality Regulated by the Health Insurance Portability and Accountability Act (HIPAA) Completed reports must be kept in a locked box Distribution of copies Determined by local and state regulations
Falsification of PCR Leads to poor patient care May lead to revocation of certification/license (cont.)
Falsification of PCR If an error in patient care occurs, document what did or didn t happen. Then, note steps taken (if any) to correct the situation.
Correction of Errors Draw a single horizontal line through the error. Write the correct information beside it. Do not obliterate the error. (cont.)
Correction of Errors If an error is discovered after the form is submitted: Use a different color of ink. Correct error with a single-line cross out. Initial and date the correction.
Patient Refusal Make sure the patient can make an informed, rational decision. Competent adult patients may legally refuse treatment. Age? Impaired by alcohol/drugs? Mentally competent? Impaired by medical condition? (cont.)
Patient Refusal Patients must be informed of the consequences of refusing care. Document all assessment findings. Have patient sign refusal form. Have witness sign refusal form. (cont.)
Patient Refusal Document attempts made to convince patient to go to hospital. Document actions taken to protect patient after you leave. Contact medical direction, if necessary.
Special Documentation Issues
Special Reporting Situations Multiple-casualty incident (MCI): Insufficient time to fully complete a PCR Use local forms or tags on the scene. Follow local MCI plan for documentation.
MCI Triage Tags
Special Situation Reports Infectious disease exposure Injuries to self/other providers Hazardous areas/scenes Social service referrals Child/elder abuse (cont.)
Special Situation Reports Document unusual events. Provide additional supplements to PCR. Follow local guidelines for confidentiality.
Enrichment Alternative methods used for PCR charting: SOAP Subjective Objective Assessment Plan (cont.)
Enrichment Alternative methods used for PCR charting: CHART Chief complaint History Assessment Rx treatment Transport
Review Questions 1. Explain the term minimum data and why it is important. 2. Explain what is meant by objective and subjective information in the narrative portion of the prehospital care report. Explain what is meant by a pertinent negative. (cont.)
Review Questions 3. Explain how spelling and the use of codes, abbreviations, and medical terms relate to writing a clear and accurate narrative report. 4. List some important steps to take and information to include when documenting a patient refusal. (cont.)
Review Questions 5. Describe some possible consequences of falsifying information on a prehospital care report. 6. Describe how to properly correct an error in a prehospital care report.
Street Scenes What information is important to include in the prehospital care report? What is the importance of doing an accurate and thorough prehospital care report? (cont.)
Street Scenes Should you have your partner read and comment on the prehospital care report before considering it complete? (cont.)
Street Scenes What are the ramifications of having a prehospital care report in the hospital record that is different from the original copy on file with your EMS agency?