EMS
Documentation
Leslie Terrell, RN, EMT-P
Education Manager
Mercy Flights, Inc
My Patient Care Report
• Why should I care?
– Document what you
did
– Document what you
didn’t do
– CYA
• Legal Document
Who sees my documentation?
• RNs, Doctors, other hospital staff
• Supervisor, management, QA Review,
Medical Director
• Patient, family, patients doctor
• Lawyers, jury
Would you remember?
• Look at a PCR from 1 year
ago
• Do you remember what
happened?
• Is there enough information
in your PCR?
• Could you go to court and
defend your actions.
Complete, Accurate
• Give all the pertinent
information
• Make sure it is
accurate
• Right Patient
• Consistent throughout
Document the situation
•
•
•
•
Set the stage
Describe what you found
Describe your actions
Explain exceptions to standards
Document what
you did
EVERYTHING that
was done to the
patient
If it is not
documented, it
was not done!
Document what you didn’t do
If it wasn’t done,
but should have been done,
Why wasn’t it done?
Spelling?
• Important?
• Appearance is reality
• Perception is everything
Adequate Description
• Does the PCR describe the situation
• Give enough details
• Would someone else see the same patient
you treated?
Abbreviations
• Dangerous – can be misinterpreted
– Some abbreviations have multiple meanings.
• Use ONLY system approved abbreviations
Cost of Errors
“medication errors are among the most
common medical errors, harming at least
1.5 million people every year”
“costs of treating these injuries in hospitals
alone amount to $3.5 billion a year”
http://onlinenursepractitionerschools.com/10-common-medical-errors-everyoneshould-know-about/
Common Errors
• Institute for Safe Medication Practices
– List of Error-Prone Abbreviations, Symbols,
and Dose Designations
• The Joint Commission
– “Do Not Use” List of Abbreviations
http://blogs.perficient.com/healthcare/blog/2011/01/04/medical-abbreviations-andthe-official-do-not-use-list/
http://www.jointcommission.org/facts_about_the_official_/
Examples
Intended dose of “.4 mg” interpreted as 4
mg from medication order. Should be
written as “0.4 mg.”
Examples
“Potassium chloride QD” in medication
order interpreted as QID. Should be written
as “daily.”
Examples
Intended recommendation of “less than 10”
was interpreted as 40. “<” should be written
out as “less than.”
Format
•
•
•
•
•
SOAP
CHART
CHARTE
Chronological
Learn what your agency uses.
SOAP Format
• Subjective:
– usually comes from the patient, family members, or
caregivers
– What the patient or bystanders tells you (reason for
the call) Chief complaint/reason for call
– Patient’s past history
– Risk factors
– Pertinent negatives
– Physical sights, sounds, smells
– Quote patient verbatim
History
– SAMPLE
– OPQRST
• Pertinent to the event or situation
• Medications
– List all pertinent medications patient is taking
• Allergies
– Ask
– What type of reaction
SOAP Format
• Objective:
– What did you see
– Physical findings from exam
– Vital signs, breath sounds
– Orderly process, neck/head to toe or body
systems approach
– Not opinion, only factual findings
– Don’t’ forget: SpO2, BGL, EKG tracings
Vital Signs
• Which ones are pertinent?
– Blood Pressure
– Pulse
– Respirations
– Sa02
– EtC02
DO NOT document Your Opinions
• Observations rather than assumptions or
conclusions
– Patient is intoxicated
– Patient does not need an ambulance
– Patient is a drug seeker.
SOAP Format
• Assessment:
– What is the patient’s problem
• based upon your subjective and objective findings
– What you believe the problem is
• Supports and is supported by your treatment plan
– If issue is obvious, then document as such
• Open fracture of the right femur
• Laceration of the right hand
• Etc…
SOAP Format
• Plan:
– Specific treatments and actions taken
• Remember to record patient’s responses to treatment
• Record any complications of treatment
– Document pre and post treatment findings
– Remember: exam, assessment and treatment must
“add up”
– Patient refusal of treatment
– ALS evaluation of BLS patients
Medical Control
• Who
• Time
• Specific orders
Avoid General Descriptors
•
•
•
•
WNL
No Abnormalities Noted
Normal
Stable
Refusals
•
Competent
– Can individual retain and comprehend
relevant information?
•
Advised of risk
– Understands risk
•
Refuses treatment/transport
Matrix of Transport Decisions
Matrix of Patient Transport Decisions
Patient Desires Transport
Yes
Yes
A:
No
C: Denial of Aid
Transport
No
B: Refusal of
Medical Assistance
EMS Desires
to Transport
D: No Transport
Matrix of Transport Decisions
B. Patient Refuses – EMS Disagrees
– True refusal of medical assistance
•
Key issue is EMS advises of need for tx/trnx and
patient refuses despite understanding risks
C. Patient Wishes Transport – EMS
Disagrees
– Significant EMS liability
•
Impossible to justify failure to tx/trnx if patient has
adverse outcome.
Matrix of Transport Decisions
D. Patient Refuses – EMS Agrees
– Example: MVA where patient did not call
•
Patient and EMS agree that no illness/injury (and
therefore risk) exist.
5 Steps in Writing Reports
• Gather facts: observe, investigate, and
interview
• Record facts immediately, take notes!
• Organize the facts
• Write the report
• Evaluate the report: edit/proofread, revise
if necessary
Changes to a PCR
• Can be done, if done appropriately
– Written PCR
• – Single line through, initial
• Addendum
– Electronic
• Change Tracking
• Addendum
• Changes made by author.
Thank You