chapter 4 - long beach city...
TRANSCRIPT
Chapter 4
Documentation
Copyright ©2010 by Pearson Education, Inc. All rights reserved.
Prehospital Emergency Care, Ninth Edition Joseph J. Mistovich • Keith J. Karren
Objectives
1. Define key terms introduced in this chapter. 2. Describe each of the following purposes served by the
prehospital care report (PCR) (slides 12-22): a. Continuity of patient care b. Administrative uses c. Legal document d. Education and research e. Evaluation and continuous quality improvement (CQI)
3. Describe characteristics, including advantages and disadvantages, of both paper and computer-based (electronic) PCR formats (slides 23-24).
Objectives
4. Explain the purposes of the U.S. Department of Transportation (DOT) minimum data set for PCRs (slide 26).
5. List the elements of the DOT minimum data set for PCRs (slides 26-27).
6. Describe the purpose and contents of each of the following sections of a PCR (slides 28-37): a. Administrative data b. Patient demographics and other patient data c. Vital signs d. Narrative e. Treatment
Objectives
7. Give examples of each of the following types of PCR narrative information (slides 34-35): a. Chief complaint b. Pertinent history c. Subjective information d. Objective information e. Pertinent negatives
8. Use common abbreviations and medical terminology accurately in PCRs (slides 63-64).
Objectives
9. Explain each of the following legal concerns with respect to the PCR (slides 38-48): a. Confidentiality b. Allowed distribution of the PCR or information included in it c. Documenting a patient’s refusal of treatment d. Falsification of the PCR e. Correction of errors
Objectives
10. Discuss how to handle each of the following situations with respect to the PCR (slides 48-55): a. Transfer of patient care when returning to service prior to
completing the PCR b. Multiple-casualty incidents (MCIs) c. Special reporting situations, such as infectious disease
exposure and suspicion of abuse or neglect
11. Accurately and completely record pertinent patient and EMS call information using the SOAP, CHART, and CHEATED methods (slides 56-62).
Topics
" Functions of the Prehospital Care Report " Collection of Data in Prehospital Care Reports " Legal Concerns " Special Situations " Alternative Documentation Methods " Medical Abbreviations
Dispatch
EMS Unit 17
Respond to 57 Vallejo Road for a vehicle versus a parked car
Time out 1321
Upon Arrival
• Female party who called 911 indicates the male who struck her vehicle was slumped over wheel
• States now he seems okay • As you approach a mid-30s male he states, “Great!
As if I didn’t have enough trouble today, I’ve got to deal with you guys! Go away. I don’t need any help!”
How would you proceed?
Back to Topics
Functions of the Prehospital Care
Report
Continuity of Medical Care
Back to Objectives
• Provides a baseline for other providers • Gives an understanding of events and
reasons for the call
Administrative Uses
• Becomes part of patient record
• Used for billing • Statistics
Legal Document
• Is legal document • May appear as a witness • Can be months or years later • May be a defense
Educational and Resource Uses
• Can look at positive or negative effects • May identify training needs
Evaluation and Continuous Quality Improvement
• Documentation part of quality improvement • Medical oversight
Back to Topics
Collection of Data in Prehospital Care
Reports
PCR Formats
Back to Objectives
• Written • Computerized
PCR Data
The Minimum Data Set
Back to Objectives
• Chief complaint • Level of
responsiveness • Blood pressure • Skin color,
temperature, and condition
• Pulse rate • Respiratory rate and
effort • Patient
demographics • Times of the call
PCR Data
Administrative Information
Back to Objectives
EMS unit and run or call number
Names of crew and levels of certification
Address to which unit is dispatched
PCR Data
Patient Demographics and Other Patient Data
• Legal name, age, sex, race, and birth date
• Home address • Location where
you found the patient
• Insurance/billing • Care rendered
prior to EMT arrival
PCR Data
Vital Signs
At least two sets should be taken prior to arrival.
PCR Data
Patient Narrative
Back to Objectives
• Chief complaint
• SAMPLE • Objective data • Subjective
data • Pertinent
negatives
PCR Data
Treatment
• Treatment • Time • Effect on patient
status
Back to Topics
Legal Concerns
Confidentiality
Back to Objectives
• Information on PCR is confidential • Be familiar with HIPAA
Distribution
• Follow state rules and local protocol for PCR distribution
• Leave a copy of PCR at receiving facility (© Ray Kemp/911 Imaging)
Refusal of Treatment
• Document competency • Document your efforts completely • Have patient sign refusal • Offer patient alternate methods of getting care • Remind patient that EMS can always return
Falsification
• Do not try to cover up mistakes • Do not compromise patient care
Falsification
Correcting Errors
• Draw single line, initial it, write the correct information beside it
• Do not erase • Do not write over
Back to Objectives
Back to Topics
Special Situations
Transfer of Care Report
• Obtain a signature from the medical professional who is assuming care
• Leave a copy of report with facility
Multiple-Casualty Incidents
• Follow local MCI plan for record keeping
• Use triage tags
(© Stephanie Ruet/Corbis Sygma)
Special Reports
• Suspected abuse • Exposures • Injuries to EMS members • Information for other agencies (© David Handschuh)
Back to Topics
Alternative Documentation
Methods
SOAP
Back to Objectives
• S – Subjective • O – Objective • A – Assessment • P – Plan
CHART
• C – Chief complaint • H – History • A – Assessment • R – Rx • T – Transport
CHEATED
• C – Chief complaint • H – History • E – Exam • A – Assessment • T – Treatment • E – Evaluation • D – Disposition
Back to Topics
Medical Abbreviations
Only use universally accepted medical abbreviations.
Examples: • BP – Blood pressure • bpm – beats per minute • CVA – Cerebrovascular accident • CHF – Congestive heart failure
Back to Objectives
Follow-Up
Assessment • You notice he has a bruise above
left eye • You are able to calm patient • He refuses all assessment and
treatment
Documentation • You note all pertinent findings • Document refusal • Have Mr. Makynen read and sign
refusal • Suggest Mr. Makynen see a doctor
or call 911 if things change • Now clear and in service
• 36-year-old female complaining of severe abdominal pain
• The patient is alert and oriented Vital signs: • BP: 88/64 mmHg • HR: 128 bpm with weak radial pulses • RR: 24 with adequate chest rise • Skin is pale, cool, and clammy • SpO2 is 96 percent on room air
Critical Thinking Scenario
SAMPLE history: • S – Feels light-headed and dizzy every
time she stands up; she’s also nauseated • A – No known allergies • M – Over-the-counter Claritin for allergies • P – No pertinent medical history; tonsils
removed when she was ten years old • L – Nothing to eat or drink for seven hours • E – Has “not felt real good” for a few days
Critical Thinking Scenario
Pain assessment: • O – Pain began suddenly and has
progressively worsened; was sitting on the couch watching television when it began
• P – Nothing makes it better or worse • Q – Dull, aching, and intermittent • R – Nonradiating • S – Eight out of ten • T – Four hours
Critical Thinking Scenario
Physical exam: • Pupils are equal and sluggish to respond • Breath sounds are equal and clear
bilaterally; no JVD • Abdomen is rigid and tender; no evidence
of trauma to the abdomen • Good motor and sensory function in all
four extremities; peripheral pulses are very weak
Critical Thinking Scenario
Repeat vital signs: • BP: 82/62 mmHg • HR: 134 bpm, radial pulses barely
palpable • RR: 26 with adequate chest rise • Skin is more pale, cool, and clammy • Pulse oximeter reading “error”
Critical Thinking Scenario
• En route to the hospital, the patient begins to close her eyes
• You must verbally instruct her to open her eyes
• For your PCR documentation: Jennifer Sampson 1321 Oakridge Drive Smithville, Ohio
Critical Thinking Scenario
1. What can this information be used for? 2. How will the medical personnel in the
medical facility use the information? 3. What will your EMS use the information
for? 4. What would you document in the patient
information section of the minimum data set?
Critical Thinking Questions
5. What would you document in the administrative section of the PCR?
6. What information would you write in the patient narrative section?
7. Should any of the information not be reported in the PCR?
8. If you were to make a mistake while writing the PCR, how would you correct it?
Critical Thinking Questions
9. If the PCR contains a box for a third set of vital signs, what would you document in this patient?
10. How would you collect additional information needed for your PCR?
Critical Thinking Questions
Reinforce and Review
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