this class covers the overall objectives and instructions for documenting ems and fire events....

This class covers the overall objectives and instructions for documenting EMS and Fire Events. Kennewick Fire Department Documentation Program

A Message From Deputy Leonard

OBJECTIVES Improve the overall documentation & review practices of the Kennewick Fire Department. Save time and resources in accomplishing overall documentation efforts. Get away from Living the call twice Initial, Review, Quality Assurance, Finance, Administrative Provide the necessary information to not only describe our actions, but enable the department to leverage our data for justifying our current actions and forecasting ours future needs.

Current Life of an EMS PCR Fire Data Collection WIMSIS EMS Data Collection WACARES Justification Validation Protection Billing / Finance Justification Administrative Budgets WIMSIS CALL 1 2 3 4 5 6 Flow Chart / ER / PCR / Run Review / QA / Finance / Admin

Current Life of an EMS PCR Fire Data Collection WIMSIS EMS Data Collection WACARES Justification Validation Protection Billing / Finance Justification Administrative Budgets WIMSIS CALL

OBJECTIVES Continued Ensure every member of the department is documenting in a consistent and appropriate manner. Improve the efficiency of our review processes. Ensuring consistency between all of our EMS and Fire Records.

CLASS SECTIONS I.Documentation SOG II.Documenting EMS Reports in ERS. III.Adjunct documentation practices a.ECG Strips b.Waiver forms c.Refusals d.Personal Recollection Records

What does the future hold? PPACA [Obama Care]? Increased efficiency through tablets & wireless communication with the Zoll & ER. An on-line QA Process giving you early feedback.

Records & Reports Incident Reporting / Fire & EMS Revised June 20, 2013 SOG 1 VII - 1

SOG Particulars Purpose A procedure for all staff to follow when documenting. Scope Applies to all KFD personnel & shall be used for all forms of documentation. Responsibilities The Chief or designee is responsible for ensuring compliance.

Fire Reporting Basic Concepts Identified in SOG Report shall be completed for all assigned responses of Fire or EMS apparatus. Each unit that responds shall complete a report including times, delays, personnel, & a S.A.C. narrative. Situation Actions Conclusions

EMS Reporting All EMS Reports shall be filled out by the person in charge of patient care in accordance with WAC 246- 976-330 Dates & Times Medicare Fields Narrative(s) Attachments

General Reporting Parts & Pieces Apparatus Times Each unit is responsible for their own times, delays, discrepancies, etc. If a delay of total travel time, exceeds 8 minutes, an explanation of the delay shall be documented in the narrative. Auto & Mutual Aid responses into the COK will require all times to be entered. Auto & Mutual Aid responses out of the COK require only KFD times to be entered.

Fire Narratives Typically speaking all narrative (except EMS) shall answer the questions of Who, What, When, and Where. Fire narratives shall additionally follow the SAC format. Situation Upon arrival, periodic updates as incident progresses, as well as tasks are completed, changed or added. Actions Actions taken by the unit, crew, division, etc. Conclusions Results of the actions taken by the unit, crew, division, etc.

S.A.C Example Car Fire S:EN1813 arrived to 4 door passenger vehicle on residential street, with flames from engine & passenger compartment. Owner standing 50 feet away with spent extinguisher. No exposures or other hazards noted in size-up. A:Fire attack with 100 bumper pre-connect with foam, and all firefighters in full PPE. Forced hood. Doors opened without force. PD on scene performing traffic control and calling for wrecker. C:Fire extinguished with tank water. No hazards leaking from vehicle after extinguishment. After ensuring fire was out, engine placed back in service. Cleared scene AV.

S.A.C Example Structure Fire S:EN1811 arrived at the scene and staged apparatus at 9 th & Vancouver, moved personnel and tools up to scene. Assigned by IC to back-up EN1814 who was interior from the A Side, making initial attack on fire currently located in CD corner. A:Made entry with tools & 1 3/4 line and 3 personnel on air through A Side. Performed back-up without incident until EN1814 crew exited structure due to low air alarms. C:IC advised EN1811 crew to move up to Interior Attack. Captain 61 conducted face to face with EN1814 as they exited structure. IC advised EN1813 to move up to back-up. EN1814 resumed fire attack at CD corner.

Who would write a S.A.C. Narrative? Incident Commander Division Supervisor Group Supervisor Captain Individual who witnessed or performed a specific task?

Fire Investigation Narratives The fire investigation narrative shall comply with NFPA 921. It shall communicate the observations, analyses, and conclusions of the investigation. Format Descriptive Information Pertinent Facts Opinions & Conclusions See SOG D.3 for more detail.

PCR / MIR Narratives Patient Care Reports shall be written in the SOAP Format using proper English, correct spelling, capitalization, and punctuation. Any abbreviations used MUST be identified in the official Benton Franklin County EMS Protocol list. Certain types of events require specific data to be obtained, even if a patient care report is not being completed. (For Example: Motor Vehicle Accidents Assist Invalid Calls No Transport Calls (NOT Patient Refusals) Supplemental Narratives Addendums

Completion of Reports All units responding to an incident shall complete a narrative. The officer completing the report may request individuals to complete individual narratives. EMS reports must be completed within 6 hours. FUTURE?

Completion of Reports All other documentation should be completed prior to the end of shift. The Company Officer or Incident Commander is ultimately responsible for the content and completion of the report.

Medical Incident Documents & Photographs ECG Strips taped to a separate piece of paper. Transmitted 12 Leads Facility Face sheets Medication Lists ABN, PCS & Waiver Forms Refusal Forms Flow Sheets? If the document is scanned and uploaded into the records management system, it MUST be included in the hard copies forwarded to finance.

Medical Incident Documents & Photographs Pictures taken at a scene should also be uploaded into ERS. A department wide Photo and Publication SOG is needed to clarify dos and don'ts. For now ask yourself Would I want this on KEPR at 6 PM?

Quality Assurance All documentation will be reviewed by the following shift. Discrepancies in the Basic / Key Fields may be corrected by the reviewer. Discrepancies in the EMS or Narrative sections of the report MUST be corrected by the author. Upon finding a discrepancy, the reviewer will: 1. Initiate an email to the individual with a cc: copy to the persons immediate supervisor. 2. Within the email, provide a list of the issues and needs for the documentation to be considered complete. 3. The author will remedy the issues ASAP! 4. The individuals supervisor will complete the document as reviewed.

Release of Reports Copies of fire incident reports may be obtained from the Fire Administration Center M-F 8:00 AM 5:00 PM. 509-737-0911 Individuals requesting EMS reports must obtain them through the cities ambulance billing department. 509-585-4379

Key Fields NFIRS 5.0 WACARES Medicare & Medicaid Fields

Documents Left at the ER WAC 246-976-330 requires EMS to leave the following at the ER at the TIME of Patient Transfer: 1. Date & Time of emergency 2. Time of symptom onset 3. Vital Signs, including serial vitals if applicable 4. Patient Assessment Findings, to include ECG strips. 5. Procedures & Therapies provided by EMS personnel in the field. 6. Any changes in patient condition while in the care of EMS personnel. 7. Mechanism of injury or type of illness.

Significant Event Notifications When out of the ordinary or big events happen, let your immediate supervisor know. Incidents occurring on City property, or involving a KFD or City Employee. Incidents posing a potential vulnerability to the City or employee. Incidents involving large dollar values, fatalities, or of public concern. Situations which will require the closure of a business or residence by the City or fire department. Other unusual or potential news worthy events. Power, radio, computer, and other infrastructure outages or issues. Complaints from the political figures, community reps, or dignataries.

Documenting Medication Errors 6 Easy Steps 1. Correct the issue if possible. (Narcan for Morphine OD.) 2. Immediately notify the ER Physician directly. 3. Document the error completely in the PCR Narrative. 4. Notify your immediate supervisor and complete the Medication Error Form in ERS. 5. Notify the EMS Officer, to include event number and any other additional circumstances related to the error. 6. Submit a performance improvement plan to your supervisor, with a copy to the EMS Officer, identifying steps that will be taken in the future to avoid such errors in the future.

Schedule II Drug Logs & Audits Complete the drug log daily per the SOG. Ensure that any medications given during the course of treatment are documented similarly in both the EMS documentation and the drug log. Notify your immediate supervisor any time you notice a significant error or discrepancy in the log. Follow the instructions in the drug log audit form and SOG.

Schedule II Drug Logs & Audits Audits are Reviewed & Summarized EMS OfficerBattalion Chiefs Drug Log is Audited Monthly Station CaptainParamedic Daily Drug Log is Completed DailyTime of Event

Lets Take a Break!

This document shall be used to provide instruction and guidance on daily EMS and Fire Documentation in ERS, as well as a guide for call review.

Basic Info 1 Using the drop down, this field identifies the Station Area the event took place in, NOT the station who responded to the event. The incident number should always be 5 digits, starting with a 0.

Basic Info 1 Ensure the Incident Type does NOT end in 0. Try to get the best description for the event.

Basic Info 1 It is important to ensure this field is completed when, providing or receiving mutual or auto aid. (See next page.) When building a report, ensure the F Number is present.

Auto vs. Mutual Aid Auto-Aide Agreements ESZ 637 in Kennewick with RFD Station 72. BCFD #1 ESZs in 110 & 120 areas, when receiving any medical response from KFD. BCFD #1 ESZ 131 and 132 along the northern boarder of Kennewick. Mutual Aid Agreements Any time KFD provides or receives aid from another agency, outside of the parameters listed above.

BASIC 2 The PCR box should be used for ALL patients who receive an Assessment, regardless of need for treatment or transport. See SOG 1-VII-1 (Revised 2013.)

BASIC 2 Information about People Involved should be used for: Parents of minor patients Persons who do not require a PCR, such as a person involved in an accident, but not requesting an Assessment. Reporting parties or witnesses Responsible parties at a scene of a fire or alarm

Basic 3 Ensure addresses are in ALL CAPS. Special attention should be paid to this line when the event is in Richland, Pasco or Finley, as these events may not have been auto-populated by CAD. Ensure the zone is accurate. This is automatically filled by CAD based on the ESZ the address is in. If you are building the report, look for the ESZ on the rip-n-run or in I-Netviewer to identify this number.

Basic 3 Use the List to best identify the address property. NOTE: There are only three 311s in the C.O.K. Most retirement homes are 459s (Residential Board and Care.) See following slide. Ensure addresses are in ALL CAPS, even cross streets or directions.

311s vs 459s Nursing Homes (311) Calloway Gardens Life Care of Kennewick Canyon Lakes Restorative Residential Board/Care (459) Royal Columbian Canyon Lakes Park View Estates Charbonneau Most small elder care facilities

Basic 4 Look at the times for consistency and appropriateness. Anything with delays greater than 8:00 minutes should have an explanation in the narrative.

Basic 4 Remember to check the response mode even if you check mark the box, This apparatus was cancelled.

Basic 5 Do your best to get this code as close to the most appropriate field assessment or disposition as possible. Dont forget you have options like; Sick Person if nothing else seams to fit.

Basic 5 Ensure at least 1 Primary Action is taken. 32 = BLS (This even includes IVs and ECGs) 33 = ALS (Medication administration & advanced airway or CPAP) 34 = Transport

EMS Section For ANY PATIENT who has received an assessment. Use this section for each individual patient. Multiple patients should not be entered in one PCR.

Questionnaire Ensure this field is correct. Options include: Transport by EMS Transport by POV Patient Refused Care Treated and Released Dead at the Scene

Questionnaire Select all of the appropriate fields. For a patient who is Transported; a minimum of Transport and Billing MUST be checked if patient is transported. *SEE STARRED AREAS*

Questionnaire In the case of a cardiac arrest, it is very important to ensure the Cardiac Arrest box is clicked. Depending on transportation, determines if Billing and Transport is checked.

Patient Information Provide as much information about the patient as possible. SSN are not needed. Minimum Information Needed: Name (No Nicknames) Address of individual not necessarily the event. Phone number Gender Weight Race DOB converted to Age Names and Addresses in ALL CAPS & No Punctuation!

Billing Billing fields MUST include: Pick up location using the most appropriate code in the drop down. Mileage must include 3 digits, even if the first one is 0, and out to the first decimal. NO rounded numbers. The example to the left is exactly how it should be. Ensure Pickup Location correlates with event location.

Patient Complaint This should be in the patients words. If patient is unconscious or unable to speak, consider putting in Third party reports Otherwise enter reason patient was unable to provide chief complaint.

Patient Complaint Utilize all of the information available to best choose the appropriate drop downs. For Example: If the Primary Impression is respiratory in nature, more times than not the Complaint Anatomical Region would be Chest.

Vitals When possible, try to provide at least 2 sets of vital signs. Vitals should be documented in this field at a minimum. VS in the narrative are extra. Billing CANNOT occur without at least one set of vital signs!

Vitals 1 2

Injury This field shall be used for Major Traumas. Use this field to better document the location of injuries & trauma noted by you while you were with the patient.

Cardiac Use this field to best describe the events revolving around any confirmed cardiac arrest patient. Again the more detail that can be provided, the better.

Interventions Ensure this box is checked, either while completing the report or during review. At a MINIMUM, the Primary Patient Caregiver MUST be identified. ALL ALS PROCEDURES AND MEDICATIONS MUST BE ENTERED INTO THIS FIELD. If they are not, the reviewer should reject the report.

Destination Destination should be identified in both this field and narrative. Ensure you have selected the correct hospital / ER destination. Narrative should be used to correlate destination fields.

Destination Using the drop downs, (and the info on the following page), select the most appropriate information for this event.

Reason for Choosing Destination Closest Facility Typically used when others dont apply Diversion Hospital / ER diverts the patient Law Enforcement Choice For patients in custody but not driven by other protocol. Patient Choice When stable & protocol does not dictate Family Choice When stable & protocol does not dictate Protocol Cardiac, Stroke, Trauma, etc. On-line Medical Direction

When is KGH really Closer?

KRMC KGH LMC K-FSER Deciding which is the most appropriate is only HALF the issue!

Narrative Narrative shall be completed in the SOAP format: Subjective (What you were told) Objective (What you saw) Assessment (Your diagnosis) Plan (What you did in chronological order) Signature MUST be the same as what is on your certification card, followed by your credential (EMT, AEMT, paramedic).

Improving Our Subjective Narratives A complete SAMPLED Symptoms Allergies Medications Previous Medical History Last Oral Intake Events Leading Up to Now Denies If picking a patient up from an ER for Transport to another facility Please provide why the patient is being transferred!

Improving Our Objective Narratives Patient position & activity on arrival General appearance & level of consciousness Weight, ethnicity, skin, etc. Exam Findings Head to Toe, or Body Systems, or Focused exam findings Gadgets ECG, BG, SaO2, ETCO2, Vitals, etc.

Improving Our Assessments Be Specific DO NOT use Rule Out What did you treat the patient for? Examples: Exacerbation of CHF STEMI Left femur fracture secondary to MVC Penetrating trauma to left chest Insulin shock Stroke

Improving Our Plan Narratives Written chronologically BSI, exam, VS, history, BG, IV 1000 NS via 18 ga @ R AC @ WO, 25 G D50W slow IVP, recheck BG 180 mg/dl, etc. etc. etc. Give justifications C-Spine cleared per T4 Protocol Pt transported to KRMC per C9 Protocol Be specific & give results 100 mcg Fentanyl slow IV, Pt Pain down to 4/10,

Addendums When you have completed a report, date & time stamp it. Any change, clarification or addition after that MUST be done as an addendum. If you make ANY change to any part of the EMS section, make a note at the bottom of the narrative describing the change. QA Officers will also note date and time event was reviewed at bottom of narrative.

Files RULES for FILES: 1.All documentation attached to report MUST be scanned and uploaded, including ECGs. 2.Complete the waiver before scanning and uploading. 3.ECGs should be taped the back of the waiver or a blank sheet of paper, (not to the front of the report.) 4.Do NOT throw away documentation that you have scanned and uploaded. 5.Uploaded filed MUST be PDFs not JPEGs.

Custom Fields STEMI should be checked YES if you believe it was a STEMI, even if later determined not to be a STEMI.

Custom Fields Be as accurate as possible to identify this field.

Custom Fields Use this field to identify all traumas, regardless if it was a trauma system activation or not.

Trauma Section When completing the Trauma Section, identify all steps of the trauma system that were met by the patients initial presenting conditions. Include in the criteria, if trauma system activation was requested in the field.

this class covers the overall objectives and instructions for documenting ems and fire events....

Documents

ems pcr

ems apparatus

ems revised

documenting ems reports

deputy leonard slide

review qa finance admin

documentation sog

forms of documentation