DOCUMENTATION

OUTLINE

Overview value of excellent documentation

Define, discuss, review SOAP notes

Review how it should look in MEMSRR

Questions and discussion

WHY?

Patient Legacy

Continuity of Care

Legal Document

Billing

MEMSMEMS patient/run record will be legible and thoroughly

completed for each call or for each patient when more than one

patient is involved in a call. This document is our legacy of patient

care and holds information valuable to hospital providers.

Services are encouraged to leave a completed copy of the

patient/run report at the hospital before they leave. In rare

circumstances, when it is not possible to complete this record

before leaving the hospital, the services may provide the hospital

with a Maine EMS approved, one page, patient care summary.

THIS DOCUMENT DOES NOT REPLACE THE COMPLETED RUN

REPORT. Services must complete this report and make the report

available to the hospital as soon as possible.

BILLING

Be clear • Emergency vs. Transfer• Transport? • All procedures, treatments, interventions and

medications need to be listed • Spelling, Grammar, Abbreviations

SOAP

S ~ Subjective ~ What happened?

O~ Objective ~ What did you find?

A ~ Assessment ~What do you think?

P ~ Plan ~ What did you do?

THE CALL

Called to XYZ Office for a woman

who fainted

SUBJECTIVE

Tell the StoryInclude:

• Age• Chief Complaint• MOI/NOI• What, when, where, how?• SAMPLE…..OPQRST• Pertinent meds and medical history

Ambulance 7 responded for a 40 year old female who had a

syncopal episode from a standing position. Patient reports she

was at work and began to feel nauseous. Walked into break room

and passed out on floor. Coworkers report pt. slumped forward

onto recliner then slid onto carpeted floor. No obvious head or

neck involvement and no significant traumatic mechanism. No

seizure type activity noted. Pt. reports waking on the floor cold

and shivering. Pt. moved to couch with assistance. Pt. denies

head, neck, chest or back pain, sob, headache, vomiting, blurred

vision, numbness, or tingling in extremities. Pt. does report mild

dizziness and ongoing weakness. Coworkers called 911 for

assistance.

OBJECTIVE

Get Technical… do the Investigation

Include:• LOC• Head to toe report with emphasis on

appropriate detailed assessment• Vitals including skin• + ( positive findings) and – (pertinent

negatives)• Some overlap

Upon initial contact, patient lying on couch in break room, alert and

oriented to name, place, time and event. Skin warm and dry with

normal color and tone. Mild muscle tremors (shivers) in arms and

legs. Pt. does report feeling cold. Head normocephalic without

abnormality on visualization or palpation. Neck midline and intact

without pain on palpation or movement. Thoracic, lumbar and sacral

spine intact without pain on palpation or spontaneous movement.

Chest intact with equal expansion, unremarkable on visualization and

palpation. Lung sounds clear and equal bilaterally with normal tidal

volume. Breathing pattern normal. No odor on breath noted.

Abdomen soft, non- tender, atraumatic and unremarkable on

visualization and palpation to all quadrants, without masses or

rigidity noted.

Pelvis and hips stable and intact without pain or crepitus on

palpation anterior or lateral. Incontinent to urine. Legs and

knees intact and atraumatic. Arms are intact and atraumatic.

No language barrier existed between patient and providers.

Neurological Exam: Pt.’s pupils equal, round and reactive to

light. Pt. does not present with observable short or long term

memory loss or confusion. Major motor neuros intact. Gross

sensory assessment intact with normal sensation throughout.

Assessment revealed no abnormal neurological findings. CiSS

negative. All observable neurological assessments remained

unchanged during and after transport to hospital.

ASSESSMENT

What do you think is going on with

the patient

• Unsure? List what you think as possibilities

PLAN

Details of interventions and how the patient

respondedInclude :

• Treatments (splints, nebs, CPAP, etc…)• Medications (02, Normal Saline, D50, etc…)• Interventions ( Monitor, IV/INT, Bg….)

Pt. transported non-emergent to XYZ emergency

room. Pt. transported without change in status or

level of consciousness. Patients treatment plan

included full secondary assessment, detailed

neurological examination, vital signs, cardiac

monitoring, 12 lead, pulse oximetry, Bg, IV left

hand tko and supplemental oxygen. Following

hand off report to staff, patient left in hospital bed

with rails up and staff in attendance.

THANKS!

Remember if you didn’t write it, it didn’t happen

Documentation is patient care!

Be thorough and take pride in what you write

Use SOAP as a guideline

Make the most of the available drop down boxes in

MEMSRR!