Pre-Hospital Documentation
Why, What and How
R. William Worden, D.O., M.Ed.
Medical Director
City of Lawton Fire Department Emergency Medical Response Agency
Apache Emergency Medical Services / Cyril Emergency Medical Services
City of Lawton / Comanche County E-911 Dispatch Center
Great Plains Technology Center Paramedic Program
City of Guthrie Fire – Emergency Medical Services
Actual EMS Narrative
• Upon our arrival, found pt in bed with first
responders complaining of breathing
difficulty. Pt. physician saw her yesterday.
Had cold X 2 weeks. Physician said lungs
were congested. Nauseated, no vomiting.
Upon listening to lung, equal but noisy. Pt
initially put on 4 liters nonrebreather,
complained so we used 24% Venturi. Allergic
codeine. Dr. Bitlett. Pt diabetic due for insulin
8:00. Meds insulin.
Objectives
• Why we document
• Strategies for good documentation
• Components of the written report
• d-C-H-A-R-T-e method of charting
• OKEMSIS and EMBRS
Why do we document
• The Goal of Pre-hospital EMS Reports should be
to provide as perfect and complete a record as
possible thereby increasing your credibility and
professional standing within the medical
community. These Reports serve to communicate
potentially vital information concerning the
patient history, physical exam, treatment, as well
as, any response or lack there of to treatment
that very well could impact the patient's
diagnosis, welfare and further treatment.
Why do we document
• The state health department says so…
• Prehospital care report has several important
functions
– Continuity of Care
– Legal Documentation
– Education
– Administrative
– Research
– Evaluation and Quality Improvement
Why we document
• Medical uses
– Helps ensure continuity of care once the patient
care is transferred to other healthcare providers
• Legal uses
– “The content and completeness of the pre-hospital care
report directly affects the lawyer’s impression of the
incident and influences his decision of whether or not to
file a lawsuit.” - Richard A. Lazar, JD
Why we document
• Education and Research
– Can be used by researchers to demonstrate the
applicability of certain medical interventions
• 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 we document
• Quality Improvement
– Reviews of documentation are an integral part of
the quality improvement process. Remedial and
continued education courses for EMT in your area
may be based upon needs revealed by call
documentation.
Good documentation strategies
• Good documentation is accurate, precise,
comprehensive, legible, objective, timely and
unaltered.
• Developing your documentation skills is as
important as any other patient care skill
The Narrative
• You are creating a detailed picture of the
patient and events with your words
• Include descriptions of
– Dispatch information, the scene, MOI, events
leading up to the emergency
– Patients condition, HPI and PMH
– Your assessment and findings
Examples of documentation
• Pts left lower leg was found to have a fracture below
the knee. Fracture splinted in place with pillow splint
and tape.
• Assessment of pts left lower leg showed a probable
angulated fracture of tib/fib below the knee. Distal
circulation was found to be slowed but present with
capillary refill approx 7 seconds with no palpable pedal
pulses and colder skin distally. Unable to straighten fx
due to severe pain and resistance to manipulation.
Fracture splinted in place with pillow splint and tape
due to above.
Describe
• All treatments rendered and the patient’s
response to that treatment
• Specifically where and when events occurred
including a where, when and who for each
intervention performed.
• Any changes in the patients condition
Describe
• Any extenuating circumstances
– Extrication, combative patients, need for restraints
and infectious/hazardous exposures
• Use the persons own words to convey stated
information
Important information
• How was patient found? (supine, in bed, bed rails up,
seated, standing, etc)
• How was patient moved? (two-person sheet lift;
standing pivot; walked to stretcher; ambulatory with
assistance to stretcher)
• How was patient transported? (on stretcher; were
chemical/hard restraints used; in captain’s chair, etc)
• Was patient monitored enroute? (vitals; change in
condition; positioning; response to treatment; etc.)
• Where was patient delivered? (to hospital bed, room
number, MRI table, wheelchair, etc.)
d – Dispatch Information
• Any pertinent information relayed from
dispatch
• Why was 911 called
Dispatched priority 1 with LFD Engine 4 to 123
Smith Street for a unresponsive male.
C – Chief Complaint
• What the patient / family members / caregiver
tells you about the current problem
• List age and gender
Patient is unresponsive and unable to provide chief
complaint. Bystander states that patient was complaining
of chest pain just prior to collapsing.
H - History
• Include both the history of the present illness
(HPI) and pertinent past medical history
(PMH)
– Remember PMH is documented in another
section of the PCR
– Only list if pertinent to current complaint
The patient was walking down the street, stopped a
bystander and asked for help. He stated that he was
having chest pain and could not breath. He told the
bystander that he has had 5 heart attacks in the past.
A - Assessment
• Include a statement about how and where you find the patient upon your
arrival
• Include and specify (who and when) for any information that first
responders relay to you about their assessment
• The primary survey (ABCDE)
• The secondary survey (Head to Toe Exam)
• Pertinent negative and positive findings
• Results of any assessment / diagnostic equipment used, ECG, pulse ox,
capnography, blood glucose monitoring
Patient is alert and oriented to person, place, time, and event. His neuro
exam is unremarkable. Skin is warm, pink and dry. HEENT: Atraumatic, Pupils
PERRLA, airway clear of obstruction. Neck: Atraumatic, no JVD, trachea is
midline. CHEST: Symmetric and atraumatic, good chest excursion. LUNGS:
CTAB. HEART: Regular Rate Rhythm. ABDOMEN: soft non-tender. PELVIS:
Stable. Extr: No noted peripheral edema, atraumatic. POST: Exam deferred
due to spine board.
R – (Rx) – Treatment on Scene
• Include all treatment and interventions
completed on scene
• Remember to document
Oxygen, Monitor, 12-lead, V/S, PIV, ASA, NTG, Morphine.
T – Transport Information
•
•
•
•
•
Where you transported the patient
Any changes in the patient’s condition
To whom you released the patient
Any incidents that happen while enroute
This includes your ongoing assessment and
treatment evaluation.
Patient moved to stretcher using draw sheet method and
secured with all straps. Blankets placed for warmth.
Patient moved to ambulance and secured along with
crew and equipment.
Variations for E.M.R.
• Transport information may be TRANSFER OF
CARE information
Report provided to Harlem EMS, Care transitioned to
Paramedic.
e - Exceptions
• Why did patient refuse transport?
• Any advise or cautions shared with the patient
(SXS to look for, risks up to and including
death associated with refusing transport,
wound care, PCP follow-up, etc)
• Ambulance being delayed due to break down
or other circumstances.
Patient complains of cervical collar pain. States “take it off or I will kick you
in the teeth.” After explaining to the patient the risks involved with removing
the cervical collar the patient states “I don’t give a sh*t, take it off.”
Computer Documentation / E.M.R.
• Many items are included in drop down boxes
for billing purposes
• Also used to track competencies
– Intubations
– I.V.’s
– Other procedures
Problem Areas
•
•
•
•
•
•
•
Personal Opinions and Biases
Improper Abbreviations
Illegibility
Improper Correction of errors
Omissions
Poor Choice of Words
Inadequate Phrases may include:
– “Transport without incident”
– “Patient was stable”
Examples
• Encode from Dispatch
– “ EMS Unit 99 Respond to 123 Anystreet for a 43
y/o male with Chest Pain. No further information
available.”
EMS Information
• Unit 99 arrives on scene and finds a 43 y/o
male complaining of Chest Pain. Patient
reports pain for 30 minutes. Substernal with
radiation to left arm. Reports history of
previous MI and stents. Not taking aspirin or
other medications for 2 weeks.
EMS Actions
•
•
•
•
•
Aspirin per protocol
NTG per protocol
ECG shows ST Elevation in II, III, aVF
IV saline lock
Transported emergent to Gotham Medical
Center
EMS Narrative
• “Unit 99 responded to Chest Pain. Pt A&O x 3.
Given ASA, NTG, IV. Vital Signs stable in
transit. Transported to Gotham Hospital.
Report to Nurse Cratchet.”
What’s Wrong with that narrative?
• Doesn’t paint a picture.
• What exactly did EMS perform?
• Did he get better or worse?
d-C-H-A-R-T-e
•
•
•
•
•
•
•
d – Dispatch Information
C – Chief complaint
H – History
A – Assessment
R – Rx (Treatment)
T – Transport Information
e – Exceptions
d-C-H-A-R-T-e
• d – Unit 99 dispatched to 43 y/o Male with Chest Pain
• C – Chest pain for 30 minutes
• H – Started while mowing the grass. Denies shortness of breath, nausea,
vomiting. Pain radiates to left arm. Reports he has been off of his
medication (aspirin, plavix, “BP Medicine”) for the last week. Rates CP at
9/10
• A – Pt in chair, diaphoretic and pale. Primary and Secondary Survey in
report. 12 Lead ECG shows ST elevation in II, II, aVF – suspect acute MI.
• R – IV Established, Given ASA and NTG. Pain down to 4/10 after 3 doses of
NTG.
• T – Transported Emergency Status to Gotham Hospital. Vital signs
remained unchanged. Pain at 3 upon arrival. Report given to Nurse
Cratchet.
• e – Unable to transmit ECG to hospital due to equipment failure. Hospital
notified via verbal report of possible Acute MI.
Pearls of Wisdom
• Splinting
– Document distal sensation and perfusion before
and after splinting.
– Document what equipment was used to splint. (air
splint, SAM Splint)
• Negatives
– Document pertinent negative
– If patient has chest pain – document presence or
absence of Shortness of Breath
What to write on a PCR
•
•
•
•
•
•
•
Anything that you did for the patient
Anything you found during the assessment
How you found the patient
Where you left the patient
Anything unusual with the call
Who started care before you got there
If you did it, you should write it.
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What not to write on a PCR
• Any foul or objectionable language
• Anything that could be considered libel
– for example: “He was drunk”
– “Patient had an odor of intoxicating substance on
breath”
– “Patient admits to drinking two 40 ounce bottles
of beer.”
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OKEMSIS / EMBRS / Intermedix
• State required documentation
• Many-Many check boxes, drop down boxes, fill in
the blank, etc.
• Used to supplement narrative
• NOT TO BE USED IN PLACE OF THE NARRATIVE
• Used to help with QA/QI; Chart review; etc.
Conclusion
• “No job is done until the paperwork is
complete.”
• Documentation is a necessary evil
• Clear, Concise, and to the point.
• Paint a picture of what you saw and
what you did.
FEEDBACK
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rwworden@usa.net
405-771-0240