www.westchestergov.com prehospital documentation westchester county department of emergency services

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Prehospital DocumentationPrehospital Documentation

Westchester County Westchester County Department of Emergency ServicesDepartment of Emergency Services


ObjectivesObjectives

• Identify the communication and Identify the communication and documentation considerations documentation considerations for EMT’s, EMT/I’s and for EMT’s, EMT/I’s and ParamedicsParamedics

I want YOU toI want YOU towrite a great PCR!write a great PCR!


ObjectivesObjectives

• Required Data and “why” it’s requiredRequired Data and “why” it’s required

• The Do’s and the Don’tsThe Do’s and the Don’ts

• Types of FormsTypes of Forms

• Reporting ErrorsReporting Errors

Identify the following:Identify the following:


First Things First….First Things First….


Baseline Information

–Patient InformationPatient Information

• Chief complaintChief complaint

• LOC or mental statusLOC or mental status

• Vital signsVital signs


Non Patient Care InformationNon Patient Care Information

• Time EMS dispatchedTime EMS dispatched

• Time EMS enrouteTime EMS enroute

• Time EMS arrived at sceneTime EMS arrived at scene

• Time EMS unit left sceneTime EMS unit left scene

• Time EMS unit arrived at hospitalTime EMS unit arrived at hospital

• Time patient care was transferredTime patient care was transferred

Travel TimeTravel TimeTravel TimeTravel Time

Scene TimeScene TimeScene TimeScene Time

ActivationActivationTimeTime

ActivationActivationTimeTime


Problems…..Problems…..

• Information recorded incorrectly or left outInformation recorded incorrectly or left out– write down what did or did not happenwrite down what did or did not happen– steps taken to correct situationsteps taken to correct situation

• Falsifying informationFalsifying information


If You Make a Mistake….If You Make a Mistake….

• Draw line through error Draw line through error

• Initial and dateInitial and date

• Write correct info next to itWrite correct info next to it

• May add note with correct infoMay add note with correct info

• Do not erase or use correction fluidDo not erase or use correction fluid

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Examples of Data CollectionExamples of Data Collection

• Written formWritten form

• ComputerizedComputerized


• Good documentation reduces:Good documentation reduces:

• LitigationLitigation

• ComplaintsComplaints

• Therefore reduces overall risk to the EMS Therefore reduces overall risk to the EMS agency, profession, and YOU!agency, profession, and YOU!


QA & ResearchQA & Research

• Better ways and methods for patient careBetter ways and methods for patient care

• Protocols get changed Protocols get changed


QA & ResearchQA & Research

• Potential problems identifiedPotential problems identified

• Best practices identifiedBest practices identified


PCR Writing – THE ACT!PCR Writing – THE ACT!


Why Write a PCR?Why Write a PCR?

• Prehospital care report serves six functions:Prehospital care report serves six functions:– CContinuity of careontinuity of care– LLegal documentationegal documentation– EEducationducation– AAdministrativedministrative– RResearchesearch

– EEvaluation and quality improvementvaluation and quality improvement


Remember………Remember………

• Write clearly.Write clearly.

• Be objective.Be objective.

• Be accurate.Be accurate.

• If you didn’t write it, you didn’t do it.If you didn’t write it, you didn’t do it.


• Don’t pre-judgeDon’t pre-judge

• What’s the worse that could be going onWhat’s the worse that could be going on

• Be without bias or prejudiceBe without bias or prejudice

• Chronic patients (Regulars)Chronic patients (Regulars)

• Wipe the slate cleanWipe the slate clean



• State things concisely.State things concisely.

• Use short succinct sentences.Use short succinct sentences.

• K.I.S.S.K.I.S.S.

• Avoid long winded statements.Avoid long winded statements.

• Abbreviations Abbreviations (Accepted list).(Accepted list).



PCR’s Must Be….PCR’s Must Be….• Legible

• All in the same time frame

• Clear, not vague

• Easy to read

• Accurate

• Truthful


VITAL VISIONVITAL VISION

• Never record falsely, exaggerate, or make up data

• Incorrect spelling, grammar, and punctuation can be misleading, and makes you look uneducated.

• Objective information should be stated in a factual manner


Things to Think About……Things to Think About……

• Avoid/Avoid/HyphenHyphen -- (minus/negative) (minus/negative)

• SemicolonSemicolon ;; Connect related statements Connect related statements instead of using “Patient states”instead of using “Patient states”

• ColonColon :: A colon can be used instead of “is”A colon can be used instead of “is”


The 4 “P’s”The 4 “P’s”

• ProtectionProtection

• ProvidersProviders

• PatientPatient

• ProfessionProfession


ProfessionProfession

• Data

• Quality Improvement

• Risk Management

• Research


• Rule #1 “DO NO HARM”

• Know your protocols

• Not sure? Speak to Medical Control

• Be objective with your treatment

• You never know it all.

• Rule #2 “USE COMMON SENSE”


• You are not judge and jury.

• Try to do an assessment.

• Inform patient of ramifications.

• Must be an informed refusal.

• If they are: suicidal, have impaired judgment from drugs/alcohol..They have to be transported.

• Minors can’t refuse to go, contact Medical Control.


• Get a signed refusal, witnessed preferably by someone other than your partner

• Document, document, document,…….

• Cancelled, unfounded, left before arrival etc. Document, document, …..


• “You are going to wait for hours in the E.D. before you get seen.”

• “An ambulance is going to cost you $$$$”

• “Oh, you don’t want to go, okay see ya”

• “They wont do anything for you”

• “Someone could be dying while you’re tying us up with your bull #&^%”


• “This could be related to your heart, it would be a good idea if you get checked out”

• “You bent the steering wheel with your chest, there is serious potential for internal injuries”

• “You know your family isn’t going to leave you alone unless you go”


Patient

•Document what is found at Document what is found at the scenethe scene

•Document patients conditionDocument patients condition•Provide subsequent Provide subsequent

providers with information providers with information to continue careto continue care


•““Food rotting on counter tops”Food rotting on counter tops”

•““Apartment cold, heat turned off”Apartment cold, heat turned off”

•““Refrigerator empty”Refrigerator empty”

•““Large pile of newspapers and mail”Large pile of newspapers and mail”

•““Lives alone unable to get out of bed”Lives alone unable to get out of bed”

•““On the floor for 24 hrs, lg urine stain”On the floor for 24 hrs, lg urine stain”

Scene Scene AssessmentAssessment


Condition

•““Appeared in poor hygiene”Appeared in poor hygiene”

•““Incontinent of old urine and feces”Incontinent of old urine and feces”

•““Lethargic prior to O2 and warming”Lethargic prior to O2 and warming”

•““Talking to relatives not there”Talking to relatives not there”

•““Bradycardia”Bradycardia”


The ContinuumThe Continuum• MedicationsMedications

• AllergiesAllergies

• Family contactsFamily contacts

• Findings/Treatment/ChangesFindings/Treatment/Changes

• Written Run ReportWritten Run Report


The Major Malfunction…The Major Malfunction…

• Chief Complaint ; “I have chest pain”, “I’m Chief Complaint ; “I have chest pain”, “I’m dizzy”, “I can’t breath” dizzy”, “I can’t breath” What the patient c/o.What the patient c/o.

• If unable to communicate ; Call nature (Man If unable to communicate ; Call nature (Man down), (Female collapsed) Use common sense down), (Female collapsed) Use common sense judgment if it’s an unknown.judgment if it’s an unknown.

• Came in as an unknown , friend states pt. drank a Came in as an unknown , friend states pt. drank a fifth of whiskey.fifth of whiskey.


Other examples of SubjectiveOther examples of Subjective

• Prior level of functionPrior level of function

• Lifestyle/home situation, scene surveyLifestyle/home situation, scene survey

• History from patient and witnessesHistory from patient and witnesses

• Major complaintsMajor complaints

• Emotions or attitudesEmotions or attitudes

• GoalsGoals

• Response to treatmentResponse to treatment


Patient, Patient, Patient!Patient, Patient, Patient!

Subjective should be brief and to the point. Subjective should be brief and to the point. It is acceptable to use “Patient” the 1st It is acceptable to use “Patient” the 1st time, after that it’s assumed, unless time, after that it’s assumed, unless otherwise stated, that the information in otherwise stated, that the information in this section came from the patientthis section came from the patient


Check Please!Check Please!

• Put your narrative in chronological order with past Put your narrative in chronological order with past medical history, history of present illness/injury, medical history, history of present illness/injury, and changes as they occur.and changes as they occur.

• It makes your report easier to read and make It makes your report easier to read and make sense. sense.

• Do it the same way, EVERY TIME!Do it the same way, EVERY TIME!


The Patient Says….The Patient Says….• Quoting can be the most appropriate method of Quoting can be the most appropriate method of

conveying subjective information.conveying subjective information.

• VerbsVerbs States, describes, denies, indicates, c/o.States, describes, denies, indicates, c/o.

• Denial:Denial: “I don’t need to go to the hospital.” “I don’t need to go to the hospital.”

• Abusive languageAbusive language: “Keep your F#^%( hands off of : “Keep your F#^%( hands off of me!”me!”


Don’t Go It Alone…..Don’t Go It Alone…..

• All of the following information was taken from the All of the following information was taken from the patient’s daughter: Lives with daughter and daughter’s patient’s daughter: Lives with daughter and daughter’s husband.husband.

• Per wife: “He hasn’t been feeling well for several days.”Per wife: “He hasn’t been feeling well for several days.”


Objective / ObservationsObjective / Observations

• Measurements performed by the EMT.Measurements performed by the EMT.

• Observations by the EMT.Observations by the EMT.

• Compared results from treatment.Compared results from treatment.

• Primary and Secondary surveys.Primary and Secondary surveys.


When I Look at the Patient I See….When I Look at the Patient I See….

• State of consciousness: A V P U , grimaces to pain, moans to voice, answers questions but is sleepy.

• General Appearance: Thin, Obese, Pink, warm, and dry, unkempt……..

• Ataxic gait.

• Grip strength weaker on left.

• Breath sounds: Clear to auscultation. (CTA).


AAssessmentssessment

• Summary of the patients major problems.Summary of the patients major problems.

• Your sixth sense of what's going on.Your sixth sense of what's going on.

• Your impression.Your impression.

• Gives a reference point for others.Gives a reference point for others.


Examples …..Examples …..

• Chest pain, r/o M.I.Chest pain, r/o M.I.

• Acute abdominal pain, r/o etiology.Acute abdominal pain, r/o etiology.

• Acute exacerbation of COPD.Acute exacerbation of COPD.

• Respiratory arrest, 2° to exacerbation of asthma.Respiratory arrest, 2° to exacerbation of asthma.

• Multi-system Trauma.Multi-system Trauma.


• Your written note must justify your treatment.Your written note must justify your treatment.

• If you omitted treatment make it clear why.If you omitted treatment make it clear why.

• If it’s not a standing order, Medical Control must If it’s not a standing order, Medical Control must be documented and orders received. be documented and orders received.

• Who gave you the orders to treat or withhold Rx.Who gave you the orders to treat or withhold Rx.

Examples …..Examples …..


P L A N of careP L A N of care

• Patient’s treatment plan (What you did)Patient’s treatment plan (What you did)

• Treatment progressionTreatment progression

• Plans for assessment and reassessmentPlans for assessment and reassessment

• DestinationDestination

• Equipment usedEquipment used

• Medications usedMedications used

• Transfer of careTransfer of care

• Involvement of other agenciesInvolvement of other agencies


Subjective

• Don’t list irrelevant info. Info should demonstrate need for an ambulance.

• Chief complaint, brief and to the point.

• Rate pain on Borg Scale.

• Avoid documenting chronic complaints.

• Changes in mentation or function.


ObjectiveObjective

• Show baseline assessment.Show baseline assessment.

• Document changes.Document changes.

• Take vital signs, Q-15 min. if stable, Q-10 or less Take vital signs, Q-15 min. if stable, Q-10 or less if unstable. At least two sets needed to determine if unstable. At least two sets needed to determine stability.stability.

• Re-evaluate patient at least once document change Re-evaluate patient at least once document change or no change.or no change.

• Be careful in reporting mental status.Be careful in reporting mental status.


AssessmentAssessment

• Suspected problem.Suspected problem.

• R/O or R/I conditions you are treating for or R/O or R/I conditions you are treating for or strongly suspect.strongly suspect.

• If unsure describe what you see.If unsure describe what you see.


PlanPlan• Treatment make it match the S, O, and ATreatment make it match the S, O, and A

• Appropriate destinationAppropriate destination

• If your agency bills for service:If your agency bills for service:

Medicare and Medicaid Medicare and Medicaid will audit and demand will audit and demand

return of moneyreturn of money


RMARMA

• Document assessment findings and care given or Document assessment findings and care given or attempted.attempted.

• Have the patient sign the form.Have the patient sign the form.

• Have a witness sign the form. Have a witness sign the form. (Not Partner).(Not Partner).

• Include a statement that you explained the Include a statement that you explained the consequences of refusing care to the patient.consequences of refusing care to the patient.


Reportable IssuesReportable Issues

• Be familiar with required reporting in Westchester Be familiar with required reporting in Westchester County, OSHA and your Agency.County, OSHA and your Agency.– Gun shot wounds (crime scene).Gun shot wounds (crime scene).

– Animal bites.Animal bites.

– Infectious disease exposure.Infectious disease exposure.

– Suspected physical or sexual abuse.Suspected physical or sexual abuse.

– Elder or Child abuse.Elder or Child abuse.

– Multiple casualty incidents.Multiple casualty incidents.


ReportingReporting

• Child, elderly, and disabled.Child, elderly, and disabled.

• MandatedMandated reporters. reporters.

• Anonymous.Anonymous.

• Follow up.Follow up.


Five Ways to Improve Your Five Ways to Improve Your Documentation Skills!Documentation Skills!

• 1. Paint a Picture.

• Your documentation is like a canvas. Use all your senses, and make your PCR easy to read.


• 2. Use Chronological Narratives.

• Keep things in chronological order. Don’t jump around!



• 3. Stick to the Facts.

• A well-written patient care report is objective instead of subjective.



• 4.Abandon Home-Grown Abbreviations.



• 5. Spelling Counts.

• Your care may be of the highest standard, but if there are misspellings, your document becomes less credible.



Questions and AnswersQuestions and Answers

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