documentation /charting don hudson, d.o.,facep/acoep
TRANSCRIPT
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Documentation Documentation /Charting/Charting
Don Hudson, D.O.,FACEP/ACOEP
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DocumentationDocumentation
Purposes–Preserves basic patient information
–Records changes in patient condition
–Justifies treatment
–Allows continuity of care
–Satisfies regulatory requirements
–Provides data for quality control
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DocumentationDocumentation
Protection for EMS personnel Reflection of good patient care
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DocumentationDocumentation
An accurate, complete, legible medical record implies
accurate, complete, organized assessment and management
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DocumentationDocumentation
Characteristics of good medical record–Accurate
–Complete
–Legible
–Free of extraneous information
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AccurateAccurate
Document facts, observations only Do NOT speculate about patient or
incident Double-check numerical entries Recheck spellings of:
–Persons
–Locations
–Medical terms
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AccurateAccurate
If you make a mistake, document it.
It is better to record your own mistakes that for someone else to uncover them.
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CompleteComplete
Include all requested information If information requested does not apply,
note “not applicable” or “N/A” Include at least two sets of vital signs on
every patient Failure to document implies failure to
consider If you look for something and it isn’t there,
document its absence
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CompleteComplete
IF IT ISN’T DOCUMENTED, IT WASN’T
DONE!
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LegibleLegible
If you cannot read the report, you may be unable to determine what happened
Documents presented in court must “speak for themselves”
If a document cannot be deciphered, the jury has to right to ignore it altogether
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LegibleLegible
If the report is sloppy, others will assume that the care was
equally sloppy
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Free of Extraneous Free of Extraneous InformationInformation
Avoid labeling patients (“drunk”, “psych patient”)
Describe the observations you made Preface comments made by the patient
with “per the patient” or “patient stated”
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Free of Extraneous Free of Extraneous InformationInformation
Record hearsay only if applicable Do NOT record hearsay as facts Use quotation marks only if a statement is
accurate word-for-word
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Free of Extraneous Free of Extraneous InformationInformation
Avoid interjecting humor
The public does not regard EMS as a funny business
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DocumentationDocumentation
A copy of the report must be left with the patient at the receiving hospital–State law requires this
–Patient care has not legally been transferred until the receiving facility has your written report
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DocumentationDocumentation
The person who rode with the patient writes the report
All personnel who participated in care should review the report
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DocumentationDocumentation If something needs to be corrected,
correct it The sooner an error is corrected, the
more credible and reliable the change is
Mark through information so it is still readable
Then write in the new information and initial/date the change
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DocumentationDocumentation
If you have a long report, don’t hesitate to use additional pages
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DocumentationDocumentation
Avoid stating diagnostic impressions Report facts and observations If you must state a diagnostic impression
– Do so within the scope of your training
– Include the observations that led to the impression
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DocumentationDocumentation
Avoid using “possible” or “?” when the observation would have been
obvious to anyone
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DocumentationDocumentation
Be sure treatments recorded match the mechanism of injury or the diagnostic impression
If something should have been done that was not, state why
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DocumentationDocumentation
If spaces are provided for documenting times, fill them in carefully
Failing to document times implies lack of concern about the time factor
If you have a prolonged scene time, say why
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DocumentationDocumentation
If you put a monitor on the patient, a hard copy of the EKG should
accompany the report
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DocumentationDocumentation
If a patient complains of pain in a area, state what you found when you examined the area
Failure to record your observations implies that you noted the complaint, but did not investigate it
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DocumentationDocumentation
On MVCs, report –Type of collision (head-on, roll-over,
lateral impact, etc.)
–Degree of damage to vehicles
–Location of patients
–Use of seatbelts
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DocumentationDocumentation
On falls report:–Where the patient fell from
–How far the patient fell
–The surface the patient fell onto
–Why the patient probably fell
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DocumentationDocumentation
On head injuries report:–Level of consciousness
–Pupillary responses
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DocumentationDocumentation
On head injuries report:–Presence/absence of:
» Discharge from nose and ears
» Cervical pain, muscle spasm, tenderness, deformity
» Paresthesias
» Altered motor function
» Altered sensory function
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DocumentationDocumentation
On chest injuries report:–Position of trachea
–Status of neck veins, breath sounds, heart sounds
–Presence or absence of» Crepitus
» Subcutaneous air
» Paradoxical movement of chest wall
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DocumentationDocumentation
On extremity injuries report:–Distal skin color and temperature
–Presence or absence of:» Distal pulses
» Motor function
» Sensory function
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Good Documentation is NOT Good Documentation is NOT C.Y.AC.Y.A
Good Documentation is a Reflection of Good Patient
Care