Documentation
Silver Cross EMS System
Third Trimester November 2011 CME
By SCEMSS Staff
The plan today…
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Talk about documentation
Talk about the drug o’ the month
Talk about the EKG strip o’ the month
Introduce a new feature: EMT-B corner!
 Since B’s have so many new treatments and
skills in their toolbox now, we will review
them in more detail in the coming months.
Written Communication
 An important aspect of EMS
communications.
 A prehospital care report (PCR) is a
written record of an EMS response.
A PCR is a
legal document,
admissible
in court.
Importance of Documentation
 Provides for the following:
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A written record of the incident
A legal record of the incident
Professionalism
Medical audit
Quality improvement
Billing and administration
Data collection
“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 (Lawyer and public safety risk management expert)
Written Record of Incident
 May be the only source of information
for persons subsequently interested
in the event
 Record of the incident from beginning
to end
 Provides a source of identifying
pertinent reportable clinical data from
each patient reaction
Uses for PCRs
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Medical
Administrative
Research
Legal
Run data in a PCR helps
agencies to improve patient care.
Some agencies use check boxes, some use
bubble sheets, and others use electronic
documentation.
Silver Cross EMSS STRONGLY recommends
that all agencies use some form of electronic
PCR.
Paper reports - Complete both the narrative
and check-box sections of every PCR.
ePCR’s – Complete the narrative and any
required check boxes or drop-down lists.
General Considerations
 The Prehospital Care Report should
be carefully detailed and legible.
 It is viewed as a legal document and
is part of the patient’s medical record.
 Use of slang terminology or medical
abbreviations that are not universally
accepted should be avoided.
 If you do not know how to spell a
word, look it up or use another word.
Times
 Whenever possible, record all times of
treatments and assessments from the
same clock.
 It is tempting to make up times, but
that’s the kind of thing that will catch
you up in court.
Communications
 Communications with the hospital are
another important item to document.
 Document ANY medical advice or
orders you receive and the results of
implementing that advice and those
orders.
 If there were no orders, document
“no orders”.
Pertinent Negatives
 Document all findings of your
assessment, even those that are
normal.
 Example: pertinant negatives in a chest
pain patient may include “denies
difficulty breathing, denies
dizziness/weakness, denies d/n/v, denies
prior history of chest pain.”
Response to treatments
 Any time something is done to the
patient, their response should be
documented.
 For example:
 Following nitro administration, pt
reported 4/10 pain
 After oxygen given, pt reported reduced
anxiety.
 BP increased to 100/60 following bolus.
Oral Statements
 Whenever possible, quote the
patient—or other source of
information—directly.
Example: Bystanders state the patient
was “acting bizarre and threatening to
jump in front of the next passing car.”
Elements of Good
Documentation
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Accuracy
Legibility
Timeliness
Unaltered
Professionalism
Completeness
Professionalism
 Never include slang, biased
statements, or irrelevant opinions.
 “Patient was acting crazy.”
 “Crew determined patient was obviously
anxious.”
 “It was apparent patient was faking
seizure.”
Professionalism
 There are ways to say these things
without saying them.
 “Police on scene state pt has prev. psych
hx.”
 “Pt reports hx of panic attacks, states
fingers and toes are numb, states she
cannot breath although speaking in
complete sentences.”
 “During seizure activity pt was responsive
to verbal and appeared to avoid EMS
intervention.”
Narrative Writing
 Subjective: part of your narrative
comprises any information you elicit
during your patient’s history.
 Objective: part of your narrative
usually includes your general
impression and any data you derive
through inspection, palpation,
auscultation, percussion, and
diagnostic testing.
Narrative
(1 of 2)
 Narrative portion of the PCR allows
for chronological description of call.
 Don’t assume that the electronic
drop-down lists cover everything.
 Two-line narratives ending in “see above for
details” or “per below” are unacceptable.
 It’s better to say in your own words than to
just leave it to the computer.
 In court, your narrative is what counts.
Narrative
(2 of 2)
 The PCR is a legal document and part
of the patient’s medical record.
 Use of slang or medical abbreviations
that are not universally accepted
should be avoided.
 Is TX transport or treatment?
 Is CO “complains of” or carbon
monoxide?
 Is CP chest pain or cerebral palsy?
Two Main Narrative Formats
 CHART
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Chief complaint
History
Assessment
Rx (treatment)
Transport
 SOAP
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Subjective
Objective
Assessment
Plan
These days SOAP is preferred, although really we don’t
care what you use as long as it’s complete and thorough.
SOAP Format
 S = Subjective
 O = Objective
 A = Assessment
 P = Plan
Subjective
 What the patient
TELLS you!
– family, friends,
bystanders –use their
words in quotes or
paraphrased
 Age, gender
 Chief complaint,
History of Illness
 Allergies, PMH, med
list
 Pertinent negatives
Objective
 What you See, Hear,
Touch, Smell!
 Paint picture from
beginning to end.
 Document assessment
 Vitals, Glasgow/Trauma
Score, EKG
 Scene information
(MVA, etc)
Assessment
 S+O=A
 Look at the whole picture: What your
impression or conclusion is.
 Example:
 Difficulty breathing unknown cause
 Chest pain, possible MI
 Right leg pain due to stick impalement.
Plan
 Step by step synopsis of what you
did and how the patient responded
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Primary assessment
Oxygen applied, Pox 84%
Needle decompression, left
Secondary assessment
Pox 93%, report called, no ? or comments
Care turned over to ED RN
Documentation Revisions
 When: as soon as the need for
revision is identified.
 Date and time of revision must be
documented.
 Always made by the original author of
the document being revised.
The Proper Way to Correct an
electronic PCR
 All of the programs in use in Silver
Cross EMSS have an addendum
function.
 Hand-written changes in an electronic
PCR must be reflected in all copies.
 Usually not do-able.
The Proper Way to Correct a
Written Prehospital Care Report
Special Considerations
 Patient refusals
 Services not needed
 Leaving the ED before finishing your
PCR
 Psychiatric patients
Patient Refusals
 Patients retain the right to refuse
treatment or transportation if they
are competent to make that decision.
 Two main types of refusals:
 Person who is not seriously
injured and does not want to go to
the hospital.
 The patient refuses even though
you feel he needs it.
A patient’s refusal of care
requires careful documentation.
Services Not Needed
 You don’t need to complete a PCR for
every invalid assist or well-being
check.
 However if you perform an
assessment and/or care, you must fill
out the appropriate documenation.
 Patient refusals make up more than
half of all court cases!
Consequences of
Inappropriate Documentation
(1 of 2)
 Inappropriate documentation has both
medical and legal consequences.
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Do not guess about patient’s problems.
Write neatly, clearly, and legibly.
Complete your form thoroughly.
Spelling counts!
Consequences of
Inappropriate Documentation
(2 of 2)
 The primary caregiver is responsible
for charting the run report (usually the
medic or EMT in the back of the box).
 Prior to your agency releasing
subpoenaed information, an attorney
should determine if a supplemental
report needs to be created.
So what happens if….
 ….you get a call before you have finished your
PCR at the hospital?
 The PCR is part of the patient record.
 You must return to ED ASAP to complete it.
 By law, a PCR must physically be left by crews in the
ED.
 Some programs allow you to fax from the road.
 But if you blindly fax, you have no idea if it ever
made it to its destination.
 New fax machine in medic room at SCH will allow you
to quickly print out from your laptop computers.
Documenting Psychiatric Patients
Adult psychiatric patients who are…
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Alert
Oriented,
Answer questions appropriately
And are no danger to themselves or others
…have the right to refuse care.
Must sign refusal like anyone else,
mental status must be completely
documented on PCR.
When Do They Have to Go
Whether They Want to Or Not?
Patients who:
 display an inability to make a rational
judgment
 pose a threat to themselves or others
Your documentation of this transport
against their will is crucial to any court
proceedings that may come later.
If they are going….
 If they agree to go, you fill out the
PCR as normal.
 Detail their willingness, including
witnesses, so they can’t claim later they
were “forced”.
 If they don’t agree to go, this is when
we utilize psychiatric petitions.
What’s a Petition
 A petition is a paper form.
 States someone feels someone else is danger
to self or others
 States the signer feels the patient requires
involuntary psychiatric treatment.
 A petition does not “commit” someone.
 Just allows ER docs to move on to next step
 Next step: seeking certificate for involuntary
admission to psych facility.
And then….
 If a judge does not approve the
certificate from the ER doc, nothing
happens.
 The petition signed by you only
gets the process rolling… it’s not
the end of the process.
Who Can Fill Out a Petition?
 Whomever witnesses dangerous or suicidal behavior can
fill out petition.
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Family members
Bystanders
Police
Us
Why us?
 Sometimes lay people are reluctant to sign petitions
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Don’t want to feel like they are responsible for “committing”
someone.
 Sometimes police don’t want to fill out petitions
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They may not understand the process or been incorrectly told it’s
our problem.
 So: if paramedics are the only witnesses to the behavior
willing to fill out a petition, then they should do so…
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For the sake of their patient.
On the Other Hand….
 If you personally haven’t heard
dangerous statements or witnessed the
behavior, don’t sign.
 RN’s, docs, nursing home staff, police or
others who tell you to sign when you
have not personally heard statements or
witnessed behavior are incorrect.
Documentation of Petitions
 Petition paperwork includes space for
narrative
 But you must also thoroughly document
the petition process in your PCR.
 Include scene details, patient condition,
reluctance by patient, police or
witnesses.
General Tips for Documentation
Take notes, chart ASAP
Clear, concise, legible, leave no blank spaces
Approved abbreviations/symbols
Black ink, no whiteout or erasing
Military time
Response to interventions
Sign with full name & title immediately after
last sentence
 C.Y.A.: Not charted means NOT DONE!!!
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Silver Cross EMSS Drug O’ the Month
Glucose/Dextrose
Oral Glucose
 A gel mix of dextrose (sugar) and water.
 Used to raise low blood sugar.
 Self-administered or given by EMS.
 Only patients with intact gag reflex (awake)
 Taste compares to super-sweet frosting.
 Patient can swallow or allow gel to stay
in mouth momentarily.
 Glucose molecules will absorb directly
though oral tissue or the small intestine.
Dextrose 50%
 Also known as D50W
 For hypoglycemia, hyperkalemia, AMS
without known cause, seizures
 Given IVP.
 Bigger catheter is better.
 Thick and hard to push through smaller
catheters.
 Dextrose can sclerose veins and lead to
tissue necrosis.
 No hand IV’s. No positional IV’s.
EMT-B Corner
The Glucometer
 You could always give oral glucose for low
blood sugar.
 Now in the new SMO’s you can also give
glucagon intranasally via the MAD device.
 So the next obvious skill step: we want you to
check blood sugars with glucometers.
 Since many B’s are not familiar with that skill,
here’s a quick recap.
Testing Tips
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Of course you should always be wearing gloves.
Choose a finger.
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Insert a test strip into your meter.
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Some models like you to put the blood on the strip before testing. Know your
model.
Use lancing device on SIDE of fingertip to get drop of blood.
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Diabetic patients will often tell you which finger they prefer.
Wipe finger with alcohol wipe, let dry completely.
Closer to the nail the better… people need the pads of their fingers to do stuff!
Or use whatever method you prefer to get the blood from an IV catheter.
You may have to squeeze or massage the finger to get enough blood out.
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But too much squeezing/massaging can change the character of the blood.
Hold hand downward to allow gravity to help.
Dexi tips continued
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Touch and hold the edge of the test strip to the drop of blood,
and wait for the result.
Blood glucose level will appear on the meter's display.
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Many models read “hi” or “low” when sugar is below 20 or above 600.
Know your meter.
Some newer meters out there let you use forearm, thigh or
fleshy part of hand.
It’s OK to use the patient’s meter in a pinch, or let him/her do
it, but always check with yours as well.
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Patient’s glucometer may not have been calibrated lately.
Plus a lot of patients are not too good at finger hygiene… eww!
ALS Strip O’ the Month
Sinus Bradycardia
Sinus Bradycardia
 If the SA node fires slower than
normal for the patient’s age, the
rhythm is called sinus bradycardia
 In adults and teens, sinus bradycardia is
a heart rate of less than 60 bpm
Sinus Bradycardia —
How Do I Recognize It?
Rate
Less than 60 bpm
Rhythm
P-P interval regular, R-R interval regular
P waves
Positive (upright) in lead II, one precedes
each QRS complex, P waves look alike
Sinus Bradycardia —
How Do I Recognize It?
PR interval
0.12–0.20 second and constant from beat
to beat
QRS duration 0.10 second or less unless an
intraventricular conduction delay exists
Sinus Bradycardia —
How Do I Recognize It?
 Sinus bradycardia at 46 bpm
 ST-segment depression
Mosby items and
derived items © 2011,
2006 by Mosby, Inc.,
Sinus Bradycardia —
What Causes It?
 Occurs in adults and
children during sleep
 Common in wellconditioned athletes
Sinus Bradycardia —
What Causes It?
 Present in up to 35% of people under
25 years of age while at rest
 Common dysrhythmia associated with
acute myocardial infarction (MI)
 Often seen in inferior and posterior
infarction
Sinus Bradycardia —
What Causes It?
 Vagal stimulation
 Coughing
 Vomiting
 Straining to have a
bowel movement
 Sudden exposure
of the face to cold
water
 Carotid sinus
pressure
Sinus Bradycardia —
What Causes It?
Inferior MI
Posterior MI
Disease of SA node
Vagal stimulation
Hypoxia
Hypothermia
Increased
intracranial pressure
 Post heart
transplant
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Hypothyroidism
Hypokalemia
Hyperkalemia
Obstructive sleep
apnea
 Medications
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 Calcium channel
blockers
 Digitalis
 Beta-blockers
 Amiodarone
 Sotalol
Sinus Bradycardia —
What Do I Do About It?
Signs and symptoms of hemodynamic compromise:
 Changes in mental
status
 Low blood pressure
 Chest pain
 Shortness of breath
 Signs of shock
 Congestive heart
failure
 Pulmonary
congestion
 Fall in urine
output
 Cold, clammy
skin
Sinus Bradycardia —
What Do I Do About It?
 No treatment if not symptomatic
 If symptomatic because of the slow
rate, treatment may include:
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Oxygen
IV access
Atropine
Transcutaneous pacing (TCP)
References
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Paramedic Practice Today: Above and Beyond, Barbara Aehlert.—
Elsevier, 1st ed.
Mosby’s Paramedic Textbook, Mick Sanders. – Elsevier, revised 3rd ed.
ECG’s Made Easy, Barbara Aehlert. – Elsevier, 4th ed.
SCEMSS staff
Any questions? Feel free to call us at 815-300-7130 or email
afinkel@silvercross.org. Thank you!