Chapter 6
Documentation
National EMS Education
Standard Competencies
Preparatory
Integrates comprehensive knowledge of the
EMS system, safety/well-being of the
paramedic, and medical/legal and ethical
issues, which is intended to improve the
health of EMS personnel, patients, and the
community.
National EMS Education
Standard Competencies
Documentation
• Recording patient findings
• Following principles of medical
documentation and report writing
National EMS Education
Standard Competencies
Medical Terminology
Integrates comprehensive anatomic and
medical terminology and abbreviations into
written and oral communication with
colleagues and other health care
professionals.
Introduction
• EMS documentation is important.
– Only written record of the call
– Legal record
– Becomes part of the:
• Patient’s medical record
• Emergency department chart
Introduction
• Know:
– What constitutes a
report
• For every call, the
PCR should
include:
– Who might read
the report
– Objective
information
– When it must be
completed
– Subjective
information
– Details of patient
care
– What terminology
may be used
Courtesy of the Utah Department of Health
Introduction
• PCRs may be written or computerized.
– Must be complete, accurate, and legible
Legal Issues of a Patient Care
Report
• Reports may include subjective statements
from the patient.
– Cannot include bias or personal opinions
• Omissions and errors can result in:
– Errors in care
– Litigation
– Job loss
Legal Issues of a Patient Care
Report
• Reports should be:
– Complete
– Well written
– Legible
– Professional
• Sloppy documentation implies sloppy care!
Confidentiality and HIPAA
• Health Insurance Portability and
Accountability Act (HIPAA)
– Protects patient privacy
– Permits disclosure for treatment, payment, and
operations
Special HIPAA Circumstances
• In some cases, patient information must be
shared, such as:
– Births
– Deaths
– Disease
– Some injury cases
– Abuse
Purposes of Documentation
• The PCR is a record of:
– The patient’s condition upon arrival
– The care provided
– Any changes in the patient’s condition
– Condition on arrival
Minimum Requirements and
Billing
• To ensure timely
billing:
– Document procedures
performed.
– Obtain insurance
codes.
– Obtain medical
necessity signature.
– Document reason
patient needed care.
EMS Research
• Many states now require EMS agencies to
submit data to their state EMS office.
– Patient care data collection can improve EMS
system as a whole.
• NEMSIS stores standardized EMS data
from each individual state.
– The goal of NEMSIS is to define EMS care.
Incident Review and Quality
Assurance
• EMS reports may be requested for medical
audits and other educational activities.
– Run reviews may occur.
• Always accurately document skills
attempted and performed with patient care.
Types of Patient Care Reports
• Most EMS reports
are electronic.
• Can be easily
shared between
facilities, personnel,
and databases
• Improves continuity
and efficiency of
care
Courtesy of Inspironix
• Advances evidencebased practice
• There are many
types of EMS
report designs.
– In some, narrative
sections have
been replaced.
• Regardless of the
form, obtain the
proper information.
Courtesy of PennCare
Types of Patient Care Reports
Types of Patient Care Reports
• Benefits of
electronic reporting:
– Ease of data
collection and
merging
– Decrease in errors
• Obstacles:
– Cost
– Technology can be
unreliable
Documentation for Every EMS
Call
• Every call requires documentation.
• Minimum data set
– Standard items documented on every call
• Run data
• Patient data
Documentation for Every EMS
Call
• PCR should contain:
– Changes in patient’s
condition
• Service treatments
may be scheduled or
unexpected.
Courtesy of Rhonda Beck
– Objective
observations
– Treatments
– Effects of treatments
Transfer of Care
• Document in whose care you left the
patient.
– Avoids allegations of abandonment
– Some agencies require nurse or physician
signatures.
– Required when you transfer a patient to another
agency
Care Prior to Arrival
• EMD may direct caller to provide care prior
to arrival.
– Off-duty providers and lay personnel may also
provide care.
• Document each situation appropriately.
Refusal of Care Reporting
• Competent, adult patients have the right to
refuse care.
– Know and understand patient rights.
• The patient should know:
– His or her current situation
– Consequences of refusal of care
Refusal of Care Reporting
• Information must be:
–
–
–
–
Given in a language the patient understands
Documented on the PCR
Witnessed by an observer
Initialed and signed by the patient
Refusal of Care Reporting
• The refusal
documentation
should clearly show:
– The process you went
through
– How the process is
documented
– Who witnessed the
process
Refusal of Care Reporting
• Unresponsive patients may be treated
under implied consent.
• Be familiar with individual state laws related
to consent.
– Confirm every effort is made to ensure patient’s
best interests.
Refusal of Care Reporting
• If you disagree with a refusal, know the next
steps.
– Document all contacted parties on PCR.
• You must have a witness to the refusal.
• Evaluate the patient’s mental status.
Refusal of Care Reporting
• Remind patient he or she can call EMS later.
• Document everything!
– Including care you intended to provide
• Propose alternate methods of care.
– Patients may agree to some treatments and
refuse others.
Workplace Injury and Illness
Documentation
• OSHA guidelines require workplace injuries
to be logged.
– Companies may require additional
documentation.
– Document precautions taken and protective
gear worn
Special Circumstances
• Multiple-casualty
incident (MCI)
– Be familiar with
triage tags.
• Occupational
exposure reports
– Used if barrier
device fails
– Know state
requirements.
• Abuse and neglect
cases
– Supply as much
detail as possible.
– Be objective.
• Physician's arrival
– Physicians may
have authority to
interject when they
arrive on scene.
Special Circumstances
• Mutual aid
services, including:
– Helicopters
– Specialized
rescue teams
• Unusual
occurrences, such
as:
– Retraining devices
– Severe weather
• Follow policy of
medical director in
special
circumstances.
• Controlled
substances
– Paramedics are
responsible for
security and
accountability.
PCR Narrative
• The PCR contains:
– Check boxes
– Narrative
• Narrative should
be:
– Detailed
– Accurate and
complete
– Specific
PCR Narrative
• Know your agency’s preferred narrative
method.
• Chronological order
PCR Narrative
• SOAP method
– Documents various aspects of the patient care
encounter
PCR Narrative
• CHARTE method
– Similar to an EMS assessment
PCR Narrative
• Body systems/parts approach
– A head-to-toe approach
• Use one reporting method consistently.
– Proper grammar and spelling are essential.
– Consider carrying a reference guide.
PCR Narrative
• Include:
– Pertinent negatives
– Spoken accounts
• Indicate who made the statement.
• Use quotation marks around the exact statement.
Elements of a Properly Written
Report
• Information should be comprehensive and
concise.
– Complete all sections, even if not applicable to
call.
• Handwritten reports should be:
– Legible
– Written in ink
– Neat and easy to read
Elements of a Properly Written
Report
• Respect patient
privacy.
• Complete in a timely
manner.
– Set aside time to
neatly complete forms
• A record should be
left with the patient.
– “Drop” or “transfer
reports” may used.
Elements of a Properly Written
Report
• A call is incomplete
until documentation
is processed.
• PCRs should not
contain:
– Jargon
– Slang
– Personal opinions
– Libel
• Review your report
before submission.
• PCRs should be:
– Complete
– Accurate
– Well-written
• Written reports
reflect on the
paramedic.
The Effects of Poor
Documentation
• Can adversely affect patient care
• Has legal implications
• Affects paramedic’s reputation
• Paperwork and reports are essential.
– Seek help if needed.
Errors and Falsification
• Avoid errors.
– If they occur, know how to address them.
• If a revision must be made:
– Note the date and time of revision.
– Include purpose for correction.
– Never discard the original.
Errors and Falsification
• Only the person who
wrote the report can
revise it.
• Routine reviews are
necessary.
• Follow protocol for
making corrections.
• The PCR is a legal
document.
Errors and Falsification
• Most electronic systems allow for revision.
• Addendums and supplemental narratives
may be needed.
– Follow your service’s policies.
• Billing information may be needed.
Errors and Falsification
• Always be honest and thorough in your
documentation.
• Lost reports have huge legal implications.
– Ensure reports are complete and turned in on
time.
– Do not keep copies of your reports.
Documenting Incident Times
• Keeping good time records is essential.
– Know which times to track, including time of:
• Call
• Dispatch
• Medication administration
– Use military time.
Medical Terminology
• Use medical terminology correctly.
• Learn accepted terms and abbreviations.
– Know slang used by your agency.
• A wide vocabulary demonstrates
competency.
Medical Terminology
• Components of a word include:
– Prefix
• Generally describes location or intensity
– Suffix
• Usually indicates procedure, condition, disease, or
part of speech
– Root word
• Conveys essential meaning; frequently a body part
Medical Abbreviations
• Can be useful
– Use approved abbreviations.
• Incorrect or inappropriate abbreviations can
have negative impacts.
• Accuracy, neatness, and completeness
reflect professional writing style.
Summary
• Each emergency call must be accompanied
by a complete formal written report as a
vital component of emergency medical care
and continuity of patient care.
• A written report should be complete, wellwritten, legible, and professional.
• Reports may be used in legal proceedings.
Summary
• HIPAA was designed to protect a person's
health information to ensure that it is only
disclosed when necessary.
• The PCR may be handwritten or
electronically written. It must include a
checklist and narrative portion and be
objective, accurate, and neat.
Summary
• If a patient refuses care, you must obtain
vital signs and a complete history, fully
inform the patient of the situation, involve
medical control if needed, and thoroughly
document the situation.
• There are special situations that may
require filling out different or additional
forms. Be familiar with your state’s
requirements.
Summary
• There are many methods for writing the
narrative in your patient care report. Learn
the method used by your system.
• Complete the patient care report directly
after the call.
• Any correction to a PCR must include the
date, time, and purpose of the correction
and have a single line placed through the
error with the correct information written
next to it.
Summary
• Falsifying information on the PCR may
result in suspension and/or revocation of
certification or license.
• Inaccurate or poor documentation might
lead to inappropriate patient care and may
be detrimental to the EMS professional.
• Use proper terminology and medical
abbreviations in all reports.
Credits
• Chapter opener: © Mark C. Ide
• Backgrounds: Green – Courtesy of Rhonda Beck;
Blue – Courtesy of Rhonda Beck; Lime – ©
Photodisc; Purple – Jones & Bartlett Learning.
Courtesy of MIEMSS
• Unless otherwise indicated, all photographs and
illustrations are under copyright of Jones & Bartlett
Learning, courtesy of Maryland Institute for
Emergency Medical Services Systems, or have
been provided by the American Academy of
Orthopaedic Surgeons.