Documentation

Course overview

Objectives Identify all the required components of a chart when documenting care provided by an EMS professional Describe the steps of completing a prehospital care report and the legal implications of this documentation Content 1. Introduction 1. What is Documentation? 2. PCR/ePCR 2. Purpose 1. Record Keeping 2. Data Tracking 3. Research 4. Legal Record/Defense - Court of Law 5. Quality Assurance/Improvement 6. Requirement of EMS Provider 7. Billing Purposes 3. ePCR Vs. PCR 1. Differences 2. Potential Pros/Cons to Both 3. 4. PCR ePCR Options Available - Examples 1. Call & Patient Demographics 2. Vital Signs 3. Assessment Findings 1. Signs/Symptoms 2. Physical Findings 3. Other Scene Findings (if applicable) 1. Traumatic Incident (MVA, GSW, Fall, etc.) 4. Procedure(s) & Treatment(s) 5. Narrative 6. Billing Information 7. Additional Forms 1. Trauma, Stroke, Sepsis, AMI, CPR, etc. 5. Priorities with Documentation 1. Define Patient Chief Complaint 2. Working Impression - Primary Impression 1. Multiple Impressions 3. Vital Signs 1. Initial Set 2. Repeated Sets 1. After Treatment 2. During Transport 3. Intervals (5/15 Minutes) 4. Treatments Administered 1. Response to Treatment 5. Patient Response During Transport 1. Transport Decision if Applicable 6. Thorough Narrative 6. Narrative Considerations 1. Provide Examples: 1. SOAP 2. CHART 3. Chronological Order 7. Considerations with Documentation 1. Patient Belongings - Document 2. 3. 4. 5. Transfer of Care - Provider Names, Room #, Airway Status Signatures - Approval of Transport Additional Care Providers - Patient Care Needs, Witness Errors in Care - Treatment, Medications, etc. 6. DNR/POLST/MOLST 7. Hospice Patient 8. Times - Accuracy 9. Abbreviations 8. Mandatory Reporting Requirements 1. Child 2. Elder 3. Other: 1. Adults with Mental Illness 2. Adults with Disabilities (Developmental) 3. Individuals with Nursing Facility or Adult Residential Facility 4. Resources (List) 9. Exposures (To Provider) 10. Falsification 11. Patient Refusal 1. Who Can and Cannot Refuse Ambulance Transport 2. Refusal Criteria 1. Alert & Oriented 2. GCS 15 3. less than 18 Years of Age OR Emancipated Minor 4. Patient is Not Incapacitated 5. Other - ETOH Intoxication, Illicit Drug Usage 3. Refusal Criteria Met: 1. Explain Risk to Patient 2. Seeking Care Via POV 3. Advise to Call 911 Back (As Needed) 4. Follow-up Care 4. Against Medical Advice (AMA) 5. Refusal Criteria NOT Met: 1. Seek Assistance from Family, Spouse, Etc. 2. OLMC 3. Consider Law Enforcement 4. Need for Facilitating Transport (Additional Providers) 6. Other Considerations 1. Life-Threatening Emergency 2. EMS Transport Required 3. Who Can Sign the Refusal Form?