Documentation
ECA
Temple College
Purpose of Documentation
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Patient Care
The most important reason
 Record for other health care providers to reference
at a later date
 Becomes part of patient record for later use
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Legal Record
May be used in court proceedings
 May be your sole source of reference
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Other Uses
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Medical Audit
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Quality Improvement
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Evaluate and improve individual performance
Evaluate and improve system quality
Billing and administration
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Run Review Conferences
Other Educational Forums
Gather data necessary for economic and regulatory purposes
Research
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Studies to improve patient care and system performance
Types of written reports
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Traditional written form
with check boxes and a
section for narrative.
Computerized version
where information is
filled in by means of an
electronic clipboard or a
similar device.
Did you know information “missing” in your prehospital report may prove more valuable to an
attorney than the information that is actually
written in the report….
“The missing Protocol”
Sections of a report
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Run Data
Patient Data
Narrative
Run Data
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Date
Times
Name of service
Unit number
Names of crew members
Patient Data
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Patient name
Address
Date of birth
Insurance information
Sex
Age
Nature of call or mechanism of injury
Patient Data
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Location of patient
Treatment administered prior to arrival of ECA
Signs and symptoms
Care administered by first responders
Baseline vital signs
SAMPLE history
Changes in condition.
Issues of Credibility
Misspelled words
 Illegible handwriting
 Poor writing skills
 Added information well after the
event…
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USE OF ABBREVIATIONS
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USE ONLY AUTHORIZED MEDICALLY
RECOGNIZED ABBREVIATIONS
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DO NOT MAKE UP YOUR “OWN”
ABBREVIATIONS.
Narrative Styles
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SOAP
CHARTE
Body Systems
Chronological
SOAP(E)
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Subjective
Objective
Analysis (or Assessment)
Plan
Enroute (or changes)
Liquid
SOAPE
Subjective
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Also called the history of the present
illness/injury.
Contains the patient’s symptoms or complaints.
In the patient’s own words, but skillfully
condensed.
Formally, contains the past medical history,
current medications and allergies.
Objective
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Also called the physical examination.
Contains your observations (signs).
Formally, contains the vital signs.
Avoid subjective terms: normal, poor, good, or
WNL.
Analysis
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Also called the clinical impression or
presumptive diagnosis.
It is a summary of the objective and subjective
sections.
It is not a formal diagnosis
Often includes a triage category.
Plan
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The actual plan and delivery of patient care.
Not what you wished you had done.
Rescue before resuscitation, resuscitation before
definitive treatments.
Sometimes responses to treatment are listed.
Enroute
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Also called changes or response to treatment
(especially by non-transporting first responders).
Narrative
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Written account of what occurred.
Include information that is not included in other
sections of the report.
Be Objective
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The patient was drunk.
VS
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The patient had slurred speech, smelled of alcohol, was not
able to make coordinated movements, and admitted to
drinking alcohol.
Allow reader to draw the desired
Patient Information
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Minimum information gathered at time of ECA's initial contact
with patient on arrival at scene, following all interventions and
on transfer of care or arrival at facility.
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Chief complaint
Level of consciousness (AVPU) - mental status
Systolic blood pressure for patients greater than 3 years old
Skin perfusion (capillary refill) for patients less than 6 years old
Skin color and temperature
Pulse rate
Respiratory rate and effort
For every reassessment, record time and findings.
Patient Care Errors
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You are human, you will make mistakes.
Learn from them and do not make them again
Be honest and forthcoming about your error
Falsification Issues
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Error of omission or commission occurs
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Falsification of information
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Do not try to cover it up.
Document what did or did not happen
What steps were taken (if any) to correct the situation.
Suspension or revocations of certification
Removal of ability to practice in system
Specific areas of difficulty
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Vital signs - document only the vital signs that were actually
taken.
Treatment - if a treatment like oxygen was overlooked, do
not chart that the patient was given oxygen.
Correction of Written Errors
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Errors discovered while the report form is being
written
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Draw a single horizontal line through the error, initial it and
write the correct information beside it.
Do not try to obliterate the error - this may be interpreted as
an attempt to cover up a mistake.
Errors discovered after the report form is submitted
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Preferably in a different color ink, draw a single line through
the error, initial and date it and add a note with the correct
information.
If information was omitted, add a note with the correct
information, the date and the EMT-Basic's initials.
Correction Examples
During writing
Mr. Smith complains of shortness of breath, chest
pain, and jaw arm pain
After completed
Mr. Smith complains for jaw pain.
JDF, 10/12/06
Addendum:
Mr. Smith complained of arm pain not jaw pain. This was discovered after
reviewing the original report. This addendum is intended to correct this error.
Jeff Fritz 10/13/2006 11:20 am
Patient Refusal
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Competent adult patients have the right to
determine what does and does not occur to their
body
Thus they have the right to refuse all or part of
the care you offer.
Refusals
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Perform a complete and detailed assessment
Ensure the patient is able to make a rational, informed decision,
e.g., not under the influence of alcohol or other drugs, or
illness/injury effects.
Inform the patient
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What is wrong with the patient (from detail assessment)
Why he should go to the hospital (what care can they provide)
What may happen to him if he does not (consequences)
Alternatives to transport and or treatment
Consult medical direction as directed by local protocol.
Try again to persuade the patient to go to a hospital.
Before you leave the scene
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If the patient still refuses, document any assessment
findings and emergency medical care given, then have
the patient sign a refusal form
Have a family member, police officer or bystander sign
the form as a witness.
If the patient refuses to sign the refusal form, have a
family member, police officer or bystander sign the
form verifying that the patient refused to sign.
Inform patient of your willingness to return
Document the Refusal
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Your assessment findings
What you told the patient
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What is wrong, why he should go, consequences,
alternatives, and your willingness to return.
The patient understood all of the above
What the patients comments were
Your attempts to convince the patient to go
Mass Casualty Incidents
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The local MCI plan should have some means of
recording important medical information
temporarily, e.g., triage tag, that can be used later
to complete the form.
The standard for completing the form in an
MCI is not the same as for a typical call. The
local plan should have guidelines.
Written Report
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When information of a sensitive nature is
documented, note the source of that
information, e.g., communicable diseases.
Be sure to spell words correctly, especially
medical words. If you do not know how to spell
it, find out or use another word.
Include pertinent negatives.
If you expect to find something and it is not there
 i.e. patient with chest pain who is not short of
breath
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Written Report
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Confidentiality –
the form itself and the information on the form are
considered confidential.
 Only those with a need to know should see it
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Billing
 Other health care providers who will care for patient
 This does not include other members of your
organization
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Common Errors
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Misspelled words
Poor grammar
Illegible handwriting
Unknown or improper abbreviations
Incomplete forms
Examples
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pateint
CP, TD, PERRLA
patient were bedridden
patient complains of laceration thigh pain
Report Example
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Subjective: 59 year old male complaining of
substernal chest pain that radiates to left arm
and jaw. Onset around 15:30 after argument
with son. Pain not improved or relieved with
position or breathing changes. Pain is described
as dull pressure and rated at 8/10. Pt also
complains of SOB and weakness. Pt denies
nausea, vomiting, dizziness. History: HTN.
Allergies: NKDA. Medications: Procardia
30mg/day.
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Objective: Pt sitting in chair in obvious pain.
Pt’s fist rubbing chest. Mental Status: Awake,
responds appropriate to questions Skin: cool,
diaphoretic. HEENT: 0 wounds, PEARL, No
accessory muscle use, + JVD, Bruits present.
CHEST: 0 wounds, bilateral basilar rales, non
tender, no discoloration. ABD: soft, non tender,
no masses, no wounds. PELVIS: deferred. EXT:
moves all extremities, + pulse, +sensory,
Flow chart
time 1602 1604 1610 1615 1618 1619
MS awake -------- -------- -------- -------- ----->
132/60
130/p
128/p
BP
112
118
104
HR
22
24
22
RR
MS, ASA
meds
meds
stretcher
trans arrival
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Assessment: MI – Urgent
Plan: Oxygen via NRB @ 15 lpm, vital signs,
ASA 324 mg PO, nitroglycerin 0.4 mg SL,
repeat vital signs, prepare for transport,
verbal report given to M. Smith. Pt
transported with M12