DOCUMENTATION
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 |