Lawrence Douglas County Fire & Medical EMERGENCY MEDICAL SERVICES QUALITY MANAGEMENT PROGRAM Standard Operating Guidelines - Emergency Medical Services SUBJECT: Report Writing for the EMS Program REFERENCE: NFPA 450 (2021) I. PURPOSE: LDCFM has established this document with the intent to provide the information necessary to properly document EMS responses and meet the requirements of Federal, State, and Local agencies. II. SCOPE: This guideline applies to all LDCFM personnel. III. DEFINITIONS This section left blank. IV. POLICY 1. EMS Reports are defined as reports that are to be completed for each EMS incident that has been created by the Emergency Communications Center (ECC) where patient care was provided by a LDCFM member. 2. A NFIRS report shall be completed even if the responding unit is cancelled at any time after an incident has been generated. 3. A completed EMS report consists of the NFIRS report, patient care report, a release of liability (patient refusal) if indicated, any other relevant forms, attachments or information. 4. The appropriate personnel must complete the EMS Report, and other related reports after the conclusion of an incident. 5. Release of information from all EMS Reports is centrally coordinated. Release of this information by anyone other than the Fire Chief or designee is prohibited. 6. Operations Division and Battalion Chiefs will assist the Training Chief and EMS Chief with Quality Assurance and Improvement for report writing. 1. Description LDCFM considers a EMS patient report to be complete when documentation of all aspects of patient care and pertinent call-related details has been completed. This provides thorough documentation of the service and care provided by LDCFM. It is the responsibility of every LDCFM member to write and submit complete and accurate reports. The Station Officer will ensure the Quality Assurance and Improvement portions for all EMS calls are adhered too. Quality Assurance are actions necessary to provide confidence that the service is satisfying LDCFM expectations. 2. Quality Improvement is process of working toward higher levels of performance associated with changes in system or process design. Responsibility For the purpose of EMS report writing responsibility, the LDCFM EMS provider who performed the greatest amount of assessment or patient care, including transport during the incident should generate the EMS report using ESO software. a. An EMS Report must be completed for every EMS response (one report per patient). A LDCFM member may complete only the NFIRS side for the following types of calls: Cancelled calls No patient found False alarms b. LDCFM Fire/paramedics, AEMTs and EMT-Bs (Firefighters, Engineer, Officers) shall complete one EMS report for every patient response, which includes the following: Regular incidents that include patient care. Type Black patients. Refusals. In the event of two first responding agencies, e.g. Consolidated Fire District 1 and LDCFM, each agency will complete an EMS Report for the same patient. c. If a Multiple Casualty Incident (MCI) is declared, an EMS Report must be completed for every patient LDCFM has contact with. d. The primary EMS provider is responsible for completing an EMS Report for each patient that they treat, transport, or from whom they obtain a refusal. e. If care is transferred from a LDCFM ALS provider to another ALS provider, each provider shall ensure the EMS report is complete and accurate. f. The officer, or non-patient care attendant is responsible for writing the company report (NFIRS) each time the unit responds to an incident and is responsible for ensuring completion of all station/shift reports. g. The primary care provider will be responsible for generating the EMS report before the end of the providers’ shift. 3. EMS Reports And NFIRS Type Report Quality All reports must contain accurate and detailed information. a. Quantitative data (CAD inputs, demographics etc.) collected affects decisions for LDCFM programs and budget. b. Qualitative data (narrative) needs to be accurate and descriptive to reduce LDCFM’s liability and make the report legally defensible. Cancellations 1. In the event of a call where LDCFM is cancelled prior to arriving at the scene, the appropriate NFIRS report should be completed. a. Incident Type “611” Dispatched and canceled en-route. b. Per the NFIRS standard, the only action taken can be “93” ‐ Cancelled en-route 2. If LDCFM is cancelled after going on scene but prior to patient contact, actions on scene prior to leaving shall be documented. a. The responding LDCFM unit arrives on the scene, a different but applicable Incident Code should be used. b. If LDCFM arrives on scene and is met immediately upon arrival by another crew and told they can cancel, this would not be a cancelled en-route situation. No Medical Needed 1. LDCFM arrives at a scene and no one is sick or injured, the crew should obtain the names and information of involved person(s). 2. If the involved person is a minor, the first and last name, middle initial, age, and responsible party should be obtained. 3. The NFIRS narrative will describe the circumstances and setting of the event. 311 Medical Assist 311 Medical assist includes incidents where medical assistance is provided to another agency that has primary EMS responsibility. a. A Mutual aid ambulance (Med Act, Leavenworth) arrives first or simultaneous as LDCFM, and provides and maintains patient care. b. LDCFM provides assistance or scene logistics to help facilitate moving the patient or equipment. c. If you do not provide patient care that is an “assist”. 320 – 324 Emergency Medical Service Incident A Patient is any person who has a medical complaint, a potential for illness or injury, or anyone who’s family and /or bystanders report a problem that is denied by that person. a. Any assessment or intervention including triage, taking a pulse, acquiring a blood pressure, SPO2, blood glucose, etc. b. Use your best judgment in accordance with the best interest of the individual involved in determining patient status. c. When in doubt, they’re a patient. d. No Patient information should be included in the NFIRS narrative. 320 Emergency medical service incident, other. 321 EMS call. Primary Incident type for EMS incidents when LDCFM provides patient care, including primary patient care and patient refusals. Excludes vehicle accident with injury (322) and pedestrian struck (323). 322 / 3221 Motor vehicle accident with injuries scene logistics / Motor vehicle accident w/ pt. care. Includes collision with another vehicle, fixed objects, or loss of control resulting in leaving the roadway. 323 / 3231 Motor vehicle/pedestrian accident (MV Ped) / Provide pt. care. Includes any motor vehicle accident involving a pedestrian injury where LDCFM does not provide patient care, only scene logistics. 3231 when patient care is provided by LDCFM. 324 Motor vehicle accident with no injuries. 352 Extrication of victim(s) from vehicle. Includes rescues from vehicles hanging off a bridge or cliff. Used for extrication from a vehicle calls where LDCFM provides patient care. Not for incidents where only scene logistic/extrication activities occur. 4. EMS Report Writing Procedures The “Patient Report” shall include, but not limited to: 1. Imported CAD Data and Incident/Response Information: Basic NFIRS information (verify accuracy) dispatch address, date, incident number(s), and crew names. 2. Patient Identification: Name, address, birthdates, demographics, etc. 3. The narrative will have information generated and imported over from the CAD. The narrative can be in the SOAP or CHART format, complete the narrative in a format that provides clear, concise and an organized approach to the information presented, to include the following: Chief Complaint; Current History; Past Medical History; Pertinent negatives Medications; Allergies Physical Exam Treatment and Response; Outcome/Disposition Any documented exceptions End the narrative with the author’s LDCFM ID. 4. Patient assessment not completed or not attempted will be documented as “none” or similar language and explained in the narrative. 4. Release Of Liability Procedure a. The refusal of treatment or transport to the hospital is the right of every patient who is completely competent and has the capacity to refuse care. A LDCFM refusal that contains the required information and signatures will be completed in the field, at the time of the refusal. b. Competency is a legal status of a person’s legal ability to make decisions and in general, adults are presumed to have competency and therefore the legal ability to make decisions regarding their care. c. An patient who is alert, oriented (cognition intact), and has the ability to understand the circumstances surrounding his/her illness or impairment, as well as the possible risks associated with refusing treatment and/or transport, typically is considered to have decisionmaking capacity. d. The LDCFM AEMT or Fire/Paramedic shall decide if the patient is in need of care and/or treatment after a complete history and physical exam while evaluating each patient and his/her particular circumstances. After this evaluation, the LDCFM care provider should ask the patient if he/she thinks they need care and/or transportation e. In multiple patient situations (MCI) where LDCFM personnel are caring for seriously ill or injured patients, patient care and rapid transport is a higher priority than on-scene documentation. Other AEMT’s or EMT-Bs arriving on apparatus will document refusals and non-transports. 5. Patient Refusal Report / Documentation a. The LDCFM provider will perform a physical and mental assessment of the patient. Further documented assessment should include the history of the present illness past medical history and current medications. b. Complete a physical patient assessment: One set of vital signs should be taken upon arrival and a second set prior to completion of the patient refusal. Document pertinent positives and negatives found. Document abnormalities in the patient’s appearance, cleanliness, speech or actions. c. Complete a mental assessment: Mental status for Legal Competency and Capacity. Document the ability or inability to refuse. Document the comfort level of the provider, e.g. refusing care AMA. d. Refusing Care Against Medical Advice (AMA). Document patient’s ability to meet the ‘capacity to refuse medical care’ and patient understand the nature of his/her medical condition, the risks and benefits of the proposed care and the risks of refusing the proposed care. In order for the patient to refuse treatment, he/she must be fully informed of medical advice, must be competent and must sign a patient refusal form releasing LDCFM from liability. This form must be witnessed, preferably by a non-fire department person, and signed by the attending LDCFM member. e. Adult without decision making capacity can be the highest risk documentation LDCFM providers may face. Complete, thorough and accurate documentation is a must. a. The LDCFM member involved in the patient’s care, will ensure every reasonable effort has been made in the best interest of the patient. b. When the patient is a danger to themselves or others, contact the appropriate law enforcement agency. LDCFM personnel will inform the police officer why the patient is a danger to himself/herself or to others. 6. If the patient is placed in custody, then the means of transport will be determined by the law enforcement agency. Document the officer’s name, unit number in the EMS report. Non-Treatment and Release Guidelines for Minors a. If recommended EMS services are refused, make every effort to treat and or transport the patient. This includes contacting on-line medical control to help convince the family or guardians to allow LDCFM personnel to treat and or transport the patient. b. Document the nature of the situation, including the number of attempts made to treat the patient, the possible medical consequences that were explained to those refusing/declining services, in whose adult care the patient was left, and whether or not the parties involved acknowledged this “informed refusal.” Obtain the name, phone number, and address of at least one adult witness and record it in the EMS report. c. Document the ability to refuse care and treatment from LDCFM providers by juveniles over the age of 16, with care for detailed documentation to include the attempt of the following: Their parents or guardian should still be communicated with for consent, although if unable to do such, the patient may refuse treatment and/or transportation. EVERY attempt should be made to contact parent or guardian of any patient younger than 18 years old and is preferable when available. d. Document any emergency treatment when a parent/guardian is not available to provide consent. This is known as the emergency exception rule or the doctrine of implied consent. a. For minors, this doctrine means that the EMS provider can presume consent and proceed with appropriate treatment and transport if the following four conditions are met: The child is suffering from an emergent condition that places his or her life or health in danger. The child’s legal guardian is unavailable or unable to provide consent for treatment or transport. Treatment or transport cannot be safely delayed until consent can be obtained. The EMS provider administers only treatment for emergency conditions that pose an immediate threat to the child. If a minor is injured or ill and no parent/guardian contact is possible, the provider may contact Direct Medical Oversight for guidance as needed. 7. Field Determination Of Death Documentation a. LDCFM personnel will document field determination of death that complies with LDCFM protocols. b. Complete a EMS report with all appropriate patient information included and a description of all resuscitative efforts employed if applicable, criteria outlining discontinuation of resuscitative efforts, and the time of death. If a patient meets criteria for obvious death upon an initial assessment, LDCFM personnel shall not initiate resuscitative measures including cardiopulmonary resuscitation (CPR) on the patient. If the initial patient assessment does not reveal obvious death, LDCFM personnel shall initiate treatment or resuscitative measures in accordance with applicable treatment protocols. LDCFM personnel shall document all relevant information in the EMS report for all patients. Approved DNR orders (copies acceptable) shall be scanned and attached for online record keeping if a patient is not transported.