EMS Documentation
Presence Regional EMS System
May 2015
Topics
• Functions of documentation
• Components of the written report
• Documentation of special situations
–
–
–
–
–
Refusals
Cardiac Arrest
Termination of Resuscitation
Triple Zero
Field Death Declaration
• Record maintenance requirements
Introduction
• The responsibilities of the EMT go beyond
the assessment, management, and
transport of a patient to the hospital
• The EMT must also be able to prepare a
patient care report, to document what was
completed in the prehospital setting,
should it need to be reviewed at a later
time
Why do we document?
Illinois Department of Public Health
Rules and Regulations
Section 515.350 Data Collection and Submission
a) A run report shall be completed by each vehicle
service provider for every emergency pre-hospital or
inter-hospital transport and for refusal of care.
1) One copy shall be left with the receiving
hospital emergency department, trauma center or
health care facility before leaving this facility.
Why do we document?
• A prehospital care report (PCR) has
several important functions:
–
–
–
–
–
–
Continuity of care
Legal documentation
Education
Administrative
Research
Evaluation and quality improvement
Why do we document?
• Medical uses
• Helps to ensure continuity of care once the
patient is delivered to the emergency
department
• Legal uses
• Although not the most important reason, one
of the very important reasons for
documentation is that your record may be used
in legal proceedings
Remember.....
Prehospital Care Reports are legal
documents therefore they must
be kept confidential!!
Why do we document?
• Education and Research
• Can be used by researchers to
demonstrate the applicability of certain
medical interventions
Why do we document?
• Administrative uses
• Becomes a part of the permanent medical
records maintained at the hospital for the
patient
• It will be used in preparing bills and in
submitting records to insurance companies.
Why do we document?
• Quality Improvement
• Reviews of documentation are an integral part
of the quality improvement process. Remedial
and continued education courses for EMS in
the system may be based upon needs revealed
by call documentation.
Prehospital Care Report
(PCR)
• Information provided on the PCR should
give a clear and accurate picture of
what occurred in the prehospital
environment
• There are two basic rules to follow:
• “If it wasn’t written down, it wasn’t done.”
• “If it wasn’t done, don’t write it down.”
Prehospital Care Report
(PCR)
• General completion guidelines
– Completely fill out form in its entirety
– Use proper spelling and sentence structure
– Use only approved medical abbreviations
Paper Reports
•
•
•
•
Use black ink
Correct errors in an accepted manner
Check spelling
Read report before filing
Computer Report
• Use spell check function
• Check for automatic “drop downs”
• Read report before filing
Problems with Spell-check
• “ patient is warm, oink and dry”
– Should have been PINK
• “Contacted the corner”
– Should have been Coroner
• “patient has tow lacerations”
– Should have been two
Essential Components of
Documentation
Illinois Department of Public Health
Rules and Regulations
Section 515.Appendix E Minimum Prescribed Data Elements
• General information
• Response time information
• Patient information
• Patient assessment
• Patient treatment
Essential Components of
Documentation
•
•
•
•
•
•
•
Chief complaint
History of present illness/injury
SAMPLE history
Physical exam findings
Initial and repeat vital signs
Interventions
Patient response to interventions
Methods for PCR Charting
– SOAPE
• Subjective
• Objective
• Assessment
• Plan
• Evaluation
– CHART
• Chief
complaint
• History
• Assessment
• Rx–treatment
• Transport
Documentation Tips
• Scene Size-Up
– MOI
•
•
•
•
•
•
Position of patient
Approx. speed of vehicle
Location and extent of damage to car
Airbags deployed, seatbelt usage
Distance of fall, surface landed on
Helmet or no helmet
– Any clues pertinent to patient condition (examples:
environment hot or cold, pill bottles, alcohol containers,
odors.)
Documentation Tips
• SAMPLE History to include:
– Signs and Symptoms/ History of present
illness to include OPQRST
– Allergies
– Medications
– Past Medical History
– Last Oral Intake
– Events
Documentation Tips
• Medications: (document for each dose)
– Name of medication
– Route
– Dose
– Time given
– Patient response to medication
**this includes oxygen**
Documentation Tips
• Complete all checkboxes
– Make sure checkbox information
matches written documentation
– If doing computer charting…. Beware of
automatically populated fields
Documentation Tips
• Splinting or Spinal Immobilization
– Chart PMS before AND after
application
– Chart WHAT equipment you used to
splint or immobilize a patient
Documentation Tips
• Ongoing Assessment to include:
– Repeat vital signs
• Every 5 minutes on unstable patients
• Every 15 minutes on stable patients
– Response to interventions
– Any changes in patient status
Refusals
• The PREMSS refusal form has been
devised to allow for better documentation
of refusal of treatment and/or transport
of a patient.
• In most cases only the refusal form will
need to be completed however there are
situations when a full patient care report
should be completed in addition to the
refusal form.
Refusal of Care
• Patients have a right to refuse
treatment and transport to the
hospital.
• Must meet certain criteria.
• Documentation protects EMS
from liability issues.
Duty to Act
• EMS has a Duty to Act/Duty to
Respond to calls to EMS for help:
– 911 calls
– Direct calls
Public Assist Calls
• Patient known in the community
• Assess before moving:
–
–
–
–
–
A-B-C
Quick head to toe assessment
Areas of pain
Anything different today from the past
If only lift help, document as a refusal
Review of Refusal
Criteria
• Refusal of treatment/transport
should be initiated by the patient.
• At NO time should any EMS provider
suggest or initiate a patient refusal.
• Upon refusal of treatment and/or
transport, the EMS provider should
evaluate the patient.
Evaluation - Mental
Status
• Is the patient alert and oriented to
person, place, time and event?
• Is the patient free of the influence
of drugs or alcohol?
Evaluation - Vital Signs
• Evaluate airway, breathing and circulation.
• A complete set of vital signs should be
obtained.
• If patient refuses to have vital signs
taken, the EMS provider should use
a visual and verbal assessment
to determine if vital signs
are altered.
Evaluation - MOI / NOI
• Is the scene free of significant mechanism
of injury?
• Does the patient have a life-threatening
chief complaint or evidence of significant
signs and/or symptoms?
• Is the patient free of “pertinent” medical
history?
Evaluation - Competence
– Is the patient ≥ 18 years of age?
– If the patient is not the
appropriate age:
• Does the patient proof of
emancipation?
• Is accompanied by parent or legal
guardian?
Review of Refusal
Criteria
• Explain possible risks and complications
that may occur if treatment and/or
transport are not provided.
• This may include “death or reduction in
quality of life” if the patient’s condition is
considered life threatening by the EMS
provider or Medical Control.
• If EMS feels uncomfortable with the
patient refusing treatment/transport
• Use a reasonable amount of
persuasion to try to get the patient
to consent to treatment/transport.
Refusal Form
Documentation
• Complete the PREMSS Refusal form by
answering all questions in the upper portion
of the form.
• Document scene and assessment findings
in the space labeled “Notes/Comments”.
• Document vital signs in the space provided.
Medical Control
• Medical Control must be contacted
when:
– Any question in the upper portion of the
refusal form has been answered “NO”
– If a patient refuses transport after
EMS treatment has been initiated
– All AMA refusals
• When Medical Control is contacted,
check the box next to the hospital
contacted and print the physician’s
name on the line indicated.
Signatures
• Several signatures must be obtained
on the refusal form
• The EMS provider should read aloud
the release statement to ensure that
the patient understands what he/she
is signing
Patient Signature
• The patient’s name is to be printed in the
release statement in the space provided.
• The patient (or parent/legal guardian)
should sign on the line indicated.
• If the patient refuses to sign the form,
the reason must be documented on the
refusal form.
• The patient must also initial a reason for
refusal in the space provided on the form
Against Medical Advice
• If the EMS provider and/or Medical
Control do not agree to the patient’s
refusal of treatment and/or
transport, the patient may still
choose to refuse AGAINST
MEDICAL ADVICE (AMA) provided
that the patient is not a danger to
himself or others.
EMS Provider Signature
• The EMS provider in charge must sign on
the line indicated at the bottom of the
refusal form.
• The EMS provider must also indicate with
whom the patient was left.
• If the patient is turned over to law
enforcement, the accepting officer must
sign the form and include his/her badge
number.
Witness Signature
•
•
–
–
–
–
–
A witness should also sign on the line
indicated.
Potential witnesses include any of the
following persons present at the time the
patient signs the refusal form:
Family members/friends
Law enforcement officials
Fire department personnel
Bystanders
Other EMS providers (it is recommended
that this be a last resort as a witness)
Revised PREMSS Refusal Form
• The revised form
allows the EMS
provider to document
all components of a
patient refusal using
only one form in most
cases.
• There are situations
that still require a
complete patient
care report in
addition to the
refusal form.
Revised PREMSS Refusal
Form
• A complete patient care report
should be completed in addition to
the PREMSS refusal form when:
– Any question in the upper portion of the
form is answered “NO”.
– Medical Control has been contacted for
any reason.
– Any EMS treatment has been provided.
Abandonment
• Failure to complete Refusal
Paperwork
• Failure to communicate with Medical
Control when appropriate
• Constitutes abandonment.
Quality Improvement
• A copy of all cardiac arrest PCR’s
should be sent to the EMS office
(preferably within 24-48 hours)
• A copy of all BLS PCR’s with
administration of medications (nitro,
ASA, albuterol)
• Any PCR’s requested by the EMS
office for random chart reviews
Cardiac Arrest Documentation
• CPR prior to EMS arrival
• BLS AED attached
• Initial Rhythm identified – strips
attached (PEA is not a rhythm)
• Strips match treatment given
• Treatment follows protocols
• Airway secured – documentation of
successful airway (BLS and ALS)
• Vascular access
• Transport/Termination of
Resuscitation
• Status of patient on arrival at
hospital
• Patient turn over to next level of
care
Termination of
Resuscitation ALS
• Resuscitation may be halted without a Do Not
Resuscitate order if:
– Patient is found in asystole/PEA
– Unwitnessed arrest with no bystander CPR before
arrival of EMS
– Patient remains in asystole/PEA despite the treatment
of the Asystole/PEA protocol
•
•
•
•
CPR
Airway secured
Vascular access
Epinephrine 1 mg
Termination of
Resuscitation
• In order to Terminate Resuscitative
efforts for the previous criteria
– EMS must call medical control for
permission to terminate resuscitation
– The family must be in agreement with
the termination
– EMS must call the local coroner
“Before the wheels roll.”
• The decision to terminate
resuscitation must be made before
the wheels of the ambulance roll to
transport a patient to the hospital.
•
No way to “register” a dead person.
What if?
• Patient is elderly or has significant
medical history
• Family unable to produce DNR
• Patient does not meet Triple Zero
criteria
• Family states patient did not want
resuscitation
• Now what? Contact Medical Control
Triple Zero
• A patient who is not viable and for
whom resuscitation efforts would be
fruitless
– Unconscious
– No pulse
– No respiration
Triple Zero Signs of Long
Term Death
• The patient must exhibit one or more of
the following signs
– Rigor mortis – stiffness of the limbs
– Lividity – pooling of blood in dependent parts of the
body
– Decomposition
– Mummification
– Decapitation
– No resuscitative efforts for at least 20 minutes
– No palpable pulses.
– Asystole in 3 chest leads/No shock indicated on AED
• Contact Medical Control
– Document:
•
•
•
•
•
•
Findings
Time Triple Zero confirmed
Hospital called
Physician on the radio
Coroner contacted
Patient hand off
– The “confirmation of Triple
Zero assessment” does not constitute
a pronouncement of death.
Remember to
• Call the local coroner
If any doubt exists,
resuscitate
Especially if:
suspected hypothermia
drowning/near drowning
uncertain down time
Field Death Declaration
• Chance of survival from traumatic
cardiac arrest at the scene is minimal
• Must make the best use of time,
personnel and resources
• Protocol approved for all levels of
EMS providers (FR-D, Basic,
Intermediate, Paramedic)
FDD Criteria
• Significant mechanism of injury
• Over the age of 14
• Pulseless and not breathing on EMS
arrival
• Not treatable EKG rhythm (No shock
indicated on AED)
• No signs of life
• Contact Medical Control
– Document:
•
•
•
•
•
•
Findings
Time Field Death Declaration confirmed
Hospital called
Physician on the radio
Coroner contacted
Patient hand off
– The “confirmation of FDD
assessment” does not constitute
a pronouncement of death.
Record Maintenance
• Handwritten reports (narrative and
“bubblesheet”) – PREMSS Non-transport
–
–
–
–
Must use NEMSIS compliant PCR’s
One copy each to the receiving facility
One copy each to the EMS agency
One copy each sent to the EMS office
• Copies should be sent to the EMS office on a monthly
basis
Record Maintenance
• Computerized reports
– All software used for computerized
documentation must be NEMSIS compliant
– Data must be submitted to IDPH quarterly for
all transport agencies
– One copy of report should be left at the
receiving facility at the time of the call
Review
• Answer the following questions as a group.
• If doing this CE individually, please e-mail
your answers to:
shelley.peelman@provena.org
• Use “May 2015 CE” in subject box.
• You will receive an e-mail confirmation.
Print this confirmation for your records,
and document the CE in your PREMSS CE
record book.
Review
1. List and describe the 6 functions of
prehospital documentation.
2. True or False? A prehospital care
report does not become a part of
the patient’s permanent record
therefore it does not need to be
left at the receiving facility.
Review
3. True or False? Prehospital care
reports are considered confidential
and are covered under HIPAA
regulations.
4. True or False? Prehospital care
reports are sent to the EMS office
annually.
Review
5. Name 4 essential components of
prehospital documentation.
6. What needs to be documented in a
Refusal of Care situation?
7. When do you need to call Medical
control in a Refusal of Care situation?
8.
What needs to be documented on
a cardiac arrest?
9. ALS: When can resuscitation be
terminated?
• 10. What needs to be documented
for a Triple Zero call?
• 11 What needs to be documented for
a Field Death Declaration?
• 11. What is a drawback of using spell
check with computerized documents?