Patient Care Documentation
“A Proactive Approach”
- Richard W. Patrick, B.S., EMT-P/FF
- Steven A. Forry, EMT-P
Objectives



State the importance and benefits of professional
patient care documentation.
Understand the importance of following treatment
protocols and standing orders.
Differentiate the criminal, civil, and ethical
implications of patient care documentation.
2
Objectives Con’t



Understand the responsibility to properly assess,
treat, stabilize, transport, and document the care
provided to their patient, as identified in their
scope of practice and within their standard of care.
Develop a methodology for obtaining objective
and subjective patient care information using open
and closed ended questions.
State the differences in civil, criminal, and
possibly punitive aspects of alleged malpractice.
3
Objectives Con’t

Recognize the value of prospective, concurrent,
and retrospective continuous quality improvement
through positive rather than negative
reinforcement and disciplinary action.
4
Identifying the Problem
Trip Sheet
Vs.
Patient Care Report
5
Scenario #1
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53 y/o male, c/o SOB
PMH: CHF
MEDS: Lasix
Allergies: None
Vital Signs:
–
–
162/88, P-112, R-38
168/90, P-124, R-36
6
Identifying the Problem
Coupled to the need for
quality patient care is the
need for appropriate and
thorough documentation of
your findings
7
Identifying the Problem

“a properly completed PCR can prevent a
prehospital care provider from being sued,
or, in the event that an incident is litigated,
can dramatically improve the providers
chances of winning the lawsuit.”
- Richard A. Lazar, JD
- Robert J. Schappert III
8
Identifying the Problem

“if the EMS training institutions have failed
to adequately teach EMT students to
document, they likely have also failed to
establish standards for the profession of
prehospital care.”
- The American College of Emergency Physicians
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Bad Trip Sheet

Identify the problems.
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“Bloopers”



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Patient is able to remove his neck, but it does cause some
discomfort.
Patient has two teenage children but no other abnormalities
Explained to the family that patient was at death’s door
and we were trying to pull him through
Patient suffered cardiac arrest. Resuscitation attempts
failed and patient pronounced dead. Patient requests an
autopsy.
Skin: Somewhat pale, but present.
On the second day, the knee was better, and on the third
day, it had completely disappeared.
11
Patient Assessment &
Documentation



Illness Assessment
– Head to Toe
Injury Assessment
– Head to Toe
Acronyms
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Patient Care Documentation
 PCR
must be completed on every call
 PCR must be complete for every call
 Proper abbreviations, words, and
attitude
 Readable, professional, and adequately
reflect the care given or offered to
patient
13
Patient Care Documentation
 Quotes
where appropriate and
required
 Copy given in receiving hospital for
attaching to permanent medical
record.
 Refusal form and incident report
completed
14
“If you didn’t write it,
you didn’t do it!”
Patient Refusals
First
we must understand
that a competent adult has
the right to refuse treatment
and/or transportation.
16
Patient Refusals
 The
EMS Providers Challenge:
To distinguish incompetence
from bad decision-making.
17
Patient Refusals
 Patients
who request to sign AMA
 Patients who are allowed to sign AMA
 Patient requests treatment - but no
transport
 Patient requests transport - but no
treatment
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Patient Refusals
 Patients
who should go to a
hospital
 Patients who must go to a hospital
 Patients with life threatening
illness/injury
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Patient Refusals
The
EMS provider must
always keep the best
interest of the patient at the
forefront
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Refusal Information Sheet
A document that provides information to
the victim/patient regarding their refusal of
services and offers added protection to the
EMS provider.
21
Refusal Check List
This check list is used to assist the EMS
provider in a systematic approach to assure
all venues have been exhausted during the
consideration of patient refusals.
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Patient Evaluation Sheet
The EMS Cognitive Evaluation sheet assists
with “elements of perception” in the
determination of the victim/patients level of
competence.
“Raise your right hand”
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Service Transport Form
Competent patients maintain the right to
refuse medical care and/or transportation.
This sample Refusal of Service/Transport
form builds from previous examples to aid
EMS providers when attempts to
treat/transport have been exhausted.
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The Patient Care Report
 Misspelled
words, illegible handwriting, and poor writing skills lend
themselves to questioning the
credibility of the care provider
“Just the Facts Ma’am”
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Scenario #2

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76 y/o female c/o chest pain,
nauseated, and dizzy.
PMH: Angina, Gall Bladder
Operation
MEDS: Nitro, ASA, Vitamins
Allergies: PCN
Vital Signs:
–
–
204/98, P-56, R-28
198/92, P-52, R-24
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Sample Patient Care Report Form
Although Patient Care Report forms vary in
design, content is often the same. Several
PCR’s are available for review and
discussion.
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Scenario #3

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26 y/o male walking around
acting inappropriately post
MVA.
Victim is bleeding from
head.
Possible alcohol
consumption
PMH: unknown
Vitals: Victim does not
permit V.S. to be taken.
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Patient Care Report Form
Upon call completion, fill out
your PCR and any applicable
documents.
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EMS Report Form
The PCR provides important data
for EMS Operations!
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Scenario #4

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66 y/o male c/o tightness in his
chest.
He permits Rx but refuses Tx.
PMH: Angina, Gall Bladder
surgery 10 years ago.
Meds: Nitrostat, ASA
Allergies: MS
Vitals:
188/98, P-116, R-24
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Incident Reports
 Treatment
Errors
 Equipment Malfunctions
–
Medical Devices Act
 Domestic
Situations
 Vehicle Malfunctions/Crashes
 Other
–
Infectious Disease Exposure, etc...
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Incident Report Form
Incident Report
Reference Number: _________________ Date: ______________ Shift: 24-08; 08-16; 16-24
Incident Type: ________________________________________________________________________
Unit #: __________
Time of Incident: _________
Time of Report: _________
Personnel Involved:
___________________________________
___________________________________
___________________________________
___________________________________
Incident Description:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
(continue on separate sheet if necessary)
__________________________________
___________________________________
Signature: Provider completing Report
Signature: Supervisor receiving Report
--------------------------------------------------------------------------------------------------------------------------------Department Use OnlyResolution:
Date: ___________
Time: ________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
__________________________________
Signature: Investigating Supervisor
____________________________________
Signature: Chief of Operations
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Medical Direction
Medical
Direction is not
only a necessity but an asset
to any EMS organization.
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Medical Direction
On - Line Medical Direction
vs.
Off - Line Medical Direction
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The Quality Process
Quality Assurance
&
Continuous Quality
Improvement
36
The Quality Process
EMS
personnel should
consider the Quality
Process as an intricate part
of their everyday function.
37
The Quality Process

The Seven Key Action Areas
1. Leadership
2. Information & Analysis
3. Strategic Quality Planning
4. Human Resource Development and Management
5. EMS Process Management
6. EMS System Results
7. Satisfaction of Patients and Other Stakeholders
-Malcolm Baldridge Quality Program
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Summary- What Can/Should We
do?

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
Prospective QA/QI
Active Medical
Director
Peer performance
reviews
Regular case reviews
Protocol
review/testing
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Summary- What Can/Should We
do? (con’t)



Computer based PCR
w/ protocol
compliance
PCR reviews staggered by length of
experience
Skills review & testing
40
“If you didn’t write it,
you didn’t do it!”
Dare To Be Different
From Everyone Else!
Do What’s Right!
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Questions & Answers
THANKS FOR SHARING
YOUR TIME !!