DOCUMENTATION

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INTRODUCTION

Optimal patient care requires that the EMT-I and EMT-P understands the importance of proper documentation. A well-written report can ensure the credibility of the agency, as well as, that of the person preparing the document. The following topics will be discussed during this lesson:

· The need for thorough documentation

Different purposes of the prehospital care report

Four factors needed to produce effective documentation

Documenting special incidents

LESSON OBJECTIVES

At the completion of this lesson the participants will be able to:

1. Discuss the importance of complete, thorough documentation

2. State five purposes of the prehospital report

3. State the components of good documentation

4. Discuss proper documentation when L.A County Policy Reference No. 814 is used

5. State the important components of documentation when a minor is involved

6. Discuss the required elements of documentation when a patient refuses care

7. Fill out an EMS report completely given a specific scenario

SKILLS

Complete an EMS form accurately

KEY VOCABULARY

· Chief complaint: description of the patient’s reason for seeking medical attention

· Glasgow coma scale: standardized rating system used to evaluate the degree of consciousness impairment based on eye opening, motor response, and verbal response

· History of present illness or injury: events or complaints associated with the patient’s current health problem

· Intervention: An action or skill performed by an EMT or Paramedic in response to a finding in the initial assessment or focused history and examination

· Patient care report: the official or formal documentation of the physical assessment and care provided to a particular patient

· Pertinent negative: absence of a sign or symptom that helps to substantiate or identify a patient’s condition

· Pertinent positive: presence of a sign or symptom that helps to substantiate or identify a patient’s condition

· Physical assessment: head-to-toe, hands-on examination

· Run data: specific information about a run that is documented on the patient care report

KEY CONCEPTS

The following section provides information and space for taking notes on the key concepts discussed by the instructor.

PREHOSPITAL CARE REPORT

Purpose

·        Medical report of prehospital care

·        Legal document

·        Promote quality improvement

·        Resource for continuing education

·        Administrative value

Factors for an Effective Report

Accuracy

·        All recorded data should be accurate and honest

·        Incorrect information places the recorder at risk for legal action

·        Falsifying patient records places the patient in danger

·        Purposefully recording false information can lead to revocation of your license or certificate

Clarity

·        The report should be written for the reader

·        The report should be clear and legible

·        All abbreviations or characters need to be accurate

·        Misspelled words can cause a loss of credibility

Proper Chronology

·         Time relationships of response, assessments, treatments, transport, and arrival at the hospital are critical

·         Proper documentation of times provide the physician with a history of events

·         Evaluation of each intervention helps to monitor the effectiveness of treatment

Completeness

·        Record all assessments, treatments, and reassessment procedures in their chronological order

·        Note events that effect treatment or transport, i.e. prolonged extrication time

·        Record all persons involved with providing care to the patient

·        Run data

·        Call location/Date and time of call

·        Crew names and certification numbers

·        Type of call

·        Sequential times of response

·        Patient data

·        Assessment

·        Name/Sex/Age

·        Date of birth

·        Treatment

·        Disposition

·        Chief complaint- What is the medical reason the patient summoned medical assistance?

·        History of current illness-What happened? How did it happen?

·        Physical assessment findings; include pertinent negatives and positives

·        Pertinent past medical history

·        Medications and allergies

·        Record all interventions

·        Reassessment

DOCUMENTATION WHEN THERE IS A POTENTIAL FOR SPINAL INJURY

Evaluation/Documentation

·         Mechanism of injury

·         In narrative

·         Level of consciousness

·         Glasgow

·        Loss of consciousness

·        Witnessed or by history

·        Neck or back pain

·        In narrative

·        Neurological Deficit

·        Document neuro status before and after immobilization in narrative

·        Other considerations

·        Multiple concurrent injuries

·        Intoxication

·        Document spinal immobilization performed

·        Check box under BLS Procedures

SPECIAL INCIDENT REPORT WRITING

Los Angeles County Department of Health Services Policy Reference No. 814:

Withholding of Discontinuing Cardiopulmonary Resuscitation

Criteria for Determining Obvious Death

·                    To determine obvious death, in addition to absence of respiration, cardiac activity, and neurologic reflexes, a person must suffer from one or more of the following:

·                    Decapitation

·                    Penetrating injury or blunt injury with evisceration of the heart, lung, or brain

·                    Incineration

·                    Decomposition

·                    Extrication time greater than 15 minutes, where no resuscitative measures can be performed prior to extrication

·                    Pulseless, nonbreathing victims of a multiple victim incident where insufficient medical resources preclude initiating resuscitative measures

·                    Drowning victims, when it is reasonably determined that submersion has been greater than one hour

·                    Rigor mortis/Post mortem lividity

Reference No. 814 Documentation

·                    The specific criteria which was used to determine death

·                    The condition of the patient and what, if any, resuscitation interventions were initiated

·                    If the deceased was moved, the location and the reason for movement. If movement of the deceased was authorized by the coroner, document the coroner’s case number and the coroner representative who authorized the movement

·                    If base hospital contact was made, the name of the base hospital physician and time of pronouncement of death

Los Angeles County Department of Health Services Policy Reference No. 832:

Guidelines for treatment and/or transport of a patient under the age of 18 years

Minors not Requiring Parental Consent

*          Minors who do not require parental consent are persons who:

·                    Have an emergency medical condition and their parent is not available

·                    Is married or previously married

·                    Is on active duty in the military

·                    Is 15 years or older, living separate from his/her parents and managing his/her own financial affairs

·                    Is 12 years or older and in need of care for rape

·                    Is 12 years or older and in need of care for contagious reportable disease or condition, or for substance abuse

·                    Is an emancipated minor (decreed by court and identification card by DMV

·                    Is pregnant and requires care related to the pregnancy

·                    Is in need of care for sexual assault

Reference No. 832 Concepts which Require Thorough Documentation

·                    In the absence of a parent or legal representative, minors with an emergency condition shall be treated and transported to the health facility most appropriate to the needs of the patient. This is considered involuntary consent

·                    The hospital or provider agency personnel shall make every effort to inform a parent or legal representative of where their child has been transported

·                    If prehospital care personnel believe a parent or other legal representative of the minor is making a decision which appears to be endangering the health and welfare of the minor by refusing indicated immediate care or transport, law enforcement authorities should be involved

Los Angeles County Department of Health Services Policy Reference No. 834:

·                    Be 18 years of age or be an emancipated minor

·                    Meet criteria of a minor not requiring parental consent as established in Policy Reference No. 832

·                    Be competent to make the decision

·                    To be determined competent the patient must be alert and oriented and have the capacity to understand the circumstances surrounding his/her illness or impairment and the risks associated with refusing treatment or transport

Patient Refusal of Treatment or Transport/Patient Requirements to Refuse Medical Service

EMS Personnel Responsibilities

·                    Advise the patient of the risks and consequences which may result from refusal of treatment or transport

·                    If the patient’s condition meets the criteria for Base Hospital contact, and a BLS unit is alone on scene, an ALS unit should be requested. Base hospital contact should only be made while the patient is still present

·                    Advise the base hospital of all the circumstances, including indicated care or transportation, reasons for refusal, and patient’s plans for follow-up care

·                    Have the patient or his/her legal representative, as appropriate, sign the release (AMA) section of the EMS Report form. The signature shall be witnessed, preferably by a family member.

·                    Advise the patient to seek alternative care immediately, if appropriate, or if he/she develops adverse symptoms later.

·                    If the patient requests additional medical advice, the base hospital should be involved

·                    Document thoroughly if the patient refuses to sign the AMA form

Alternatives for Patients not Competent to Refuse Medical Care

·                    The patient should be transported to an appropriate facility under implied consent. In this case a 5150 is not necessary

·                    If the base hospital determines it is necessary to transport the patient against his/her will and the patient resists, assistance from law enforcement should be requested in transporting the patient. The police may consider the placement of a 5150 hold on the patient, but it is not required for transport

·                    If prehospital care personnel believe a parent or other legal representative of the patient is acting unreasonably in refusing indicated immediate care or transport, law enforcement authorities should be involved

DOCUMENTATION OF PHYSICAL ASSESSMENT

Different Approaches

· Head to Toe

· Most commonly used in trauma cases or patients who are altered/unconscious and the mechanism of injury is unknown

· Body System

· Most commonly used for patients who are awake and alert, with an isolated medical/trauma complaint

Head to Toe Assessment

Head:

Observations: Deformity, discoloration, swelling, discharge from nose/ears, pain,

bleeding, wounds

Eyes Ecchymosis Special problems (cataracts, blind)

Pupils Sclera (red, jaundiced)

Conjunctiva (pale Dilated/pinpoint pupils

Red, lack of tears) (symmetric/round)

Ears Ecchymosis Blood or fluid

Nose Discoloration Singed nasal hair

Blood or fluid Flaring

Deformity

Mouth Cyanosis Lack of saliva

Alcohol/acetone odor

Neck:

Observations: Deformity, discoloration, swelling, bleeding, wounds

Tracheal deviation Nuchal rigidity

Distended neck veins Subcutaneous emphysema

Chest:

Observations: Deformity, discoloration, swelling, bleeding, wounds

Pain (location, PQRST) Crepitus

Paradoxical movement Symmetrical movement

Open wounds Barrel chest

Accessory muscle use Symmetry equal

Flail segment Respiratory effort

Auscultation Cough

Upper Extremities:

Observations: Deformity, discoloration, swelling, cyanosis, bleeding, wounds

Pain Skin Color

Paresthesia Posturing

Skin Temperature Paralysis

Capillary refill Equality of pulses

Numbness Skin turgor

Distal pulses Equal grips

Abdomen:

Observations: Deformity, discoloration, swelling, cyanosis, bleeding, wounds

Pain Ecchymosis

Masses Rigidity

Guarding

Pain:

Observations: Deformity, discoloration, swelling, cyanosis, bleeding, wounds

Pain Incontinence

Ecchymosis Rectal/Vaginal bleeding

Masses Pelvic stability/instability

Lower Extremities:

Observations: Deformity, discoloration, swelling, cyanosis, bleeding, wounds

Pain Posturing

Paresthesia Rotation (internal/external)

Skin temperature Paralysis

Capillary refill Equality of pulses

Shortening Skin turgor

Numbness Skin color

Distal pulses Equal grips

Body System Assessment

Cardiovascular System:

Assessment of Chief Complaint

Trauma Related Cases

· Pain (PQRST)

· Distended neck veins

· Auscultation of lungs

· Palpation

· Coughing (productive, color, frothy)

· Pedal edema

· Bruising

· Subcutaneous emphysema

· Deformity

· Flail segment

Respiratory System:

Assessment of Chief Complaint

Trauma Related Cases

· SOB

· Distended neck veins

· Auscultation of lungs

· Orthopnea

· Barrel chest

· Cough (productive, color, frothy)

· Mechanism of injury

· Pedal edema

· Accessory muscle use

· Subcutaneous emphysema

· Tracheal deviation

· Singed hair

· Distant lung sounds

· Flail chest

· Mechanism of injury

· Deformity

· Bruising

Central Nervous System:

Assessment of Chief Complaint

Trauma Related Cases

· Syncopal Episode

· Ability to move

· Speech pattern

· Seizure activity

· Posturing

· Equality of grips

· Glucometer

· Facial drooping

· Headache

· Bruising

· Head/neck/back pain

· Wounds

· Mechanism of injury

· Battle’s sign

· Raccoon eyes

· Ability to move

· Neuro status before and after spinal precautions

Musculoskeletal System:

Assessment of Chief Complaint

Trauma Related Cases

· Mechanism of injury

· Pulses distal to injury

· Pain

· Degree/percent burn

· Deformity

· Ability to move

· Bruising

· Wounds

· Neuro status/distal pulses

before and after splinting

Gastrointestinal System:

Assessment of Chief Complaint

Trauma Related Cases

· Pain (PQRST)

· Orthostatic Vital signs

· Abdomen (soft, rigid, distended)

· Nausea/vomiting

· Last bowel movement

· Mechanism of injury

· Bruising

· Wounds

Reproductive and Urinary Systems:

Assessment of Chief Complaint

Trauma Related Cases

· Pregnancy (gravida/para, month)

· Vaginal discharge (clear, blood, clots)

· Contractions (duration, frequency)

· Burning/frequency of urination

· Urine (odor, bloody)

· Prenatal care

· Last menstruation (normal)

· Feeling of bowel movement

· Pain (abdominal, flank)

· Mechanism of injury

· Bruising

· Wounds

Abbreviation	Meaning
a	Before
AA/MVA/ITA/MTA/TC	Auto accident
Abd	Abdomen
AC	Antecubital
b.i.d	Twice a day
BOW	Bag of waters
BM	Bowel movement
BP,B/P	Blood pressure
B/S	Breath sounds
B.S.	Bowel sounds
BVM	Bag-valve-mask
c	With
CAD	Coronary artery disease
cc (ml)	Cubic centimeter
C/C	Chief complaint or Conscious/coherent
C/O	Complains of
CHF	Congestive heart failure
CNS	Central nervous system
COPD	Chronic obstructive pulmonary disease
CSF	Cerebral spinal fluid
C-spine	Cervical spines
CVA	Cerebrovascular accident
D/C	Discontinue
Defib	Defibrillate
DOA	Dead on arrival
DT’S	Delirium tremens
Dx	Diagnosis
ECG, EKG	Electrocardiogram
Elix, el	Elixir
EOA	Esophageal obturator airway
ED or ER	Emergency dept/room
EDC	Expected date of confinement
Est	estimated
ETA	Estimated time of arrival
ETD	Estimated time of departure
ETOH	Ethyl alcohol
ET	Endotracheal
Exp	Expiration
Fl	Fluid
FB	Foreign body
Fx	Fracture
G	Gravida
GCS	Glasgow coma scale
GI	gastrointestinal
gm	Gram
GSW	Gunshot wound
gtt	Drop
H	Hour
HAM	History,allergy, medications
Hx	History
ICP	Intracranial pressure
Insp	Inspiratory
JVD	Jugular vein distension
Kg	Kilograms
L/LT	Left
LAC	Laceration
lb	Pound
LLQ	Left lower quadrant
LOC	Level of consciousness
LUQ	Left upper quadrant
MCI	Multiple casualty incident
MAE	Moves all extremities
Med	Medication
mg	Milligram
Min	Minutes
ml (cc)	Milliliter
NC	Nasal cannula
Neg, (-)	Negative
NKA	No known allergies
NV, N/V	Nausea and vomiting
Occ	Occasional
OD	Overdose
o.d.	Right eye
o.s.	Left eye
o.u.	Both eyes
P	After
Palp, pal	Palpation
PERL	Pupils equal and reactive to light
Pos, (+)	Positive
Prn	As needed
Pt	Patient
qh	Every hour
Q2h	Every two hours
Q	Every, each
q.i.d	Four times a day
R/RT	Right
RLQ	Right lower quadrant
s	Without
s/s	Signs and symptoms
SOB	Shortness of breath
T/A, T/C	Traffic accident/collision
TB ✓	Total body check
TIA	Transient ischemic attack
t.i.d.	Three times a day
TKO	To keep open
Tx (Rx)	Treatment
Uncon	Unconscious
Vol	Volume
VS, V/S	Vital signs
W/D	Weak and dizzy
y/o	Years old