Chapter 6 Documentation National EMS Education Standard Competencies Preparatory Integrates comprehensive knowledge of the EMS system, safety/well-being of the paramedic, and medical/legal and ethical issues, which is intended to improve the health of EMS personnel, patients, and the community. National EMS Education Standard Competencies Documentation • Recording patient findings • Following principles of medical documentation and report writing National EMS Education Standard Competencies Medical Terminology Integrates comprehensive anatomic and medical terminology and abbreviations into written and oral communication with colleagues and other health care professionals. Introduction • EMS documentation is important. – Only written record of the call – Legal record – Becomes part of the: • Patient’s medical record • Emergency department chart Introduction • Know: – What constitutes a report • For every call, the PCR should include: – Who might read the report – Objective information – When it must be completed – Subjective information – Details of patient care – What terminology may be used Courtesy of the Utah Department of Health Introduction • PCRs may be written or computerized. – Must be complete, accurate, and legible Legal Issues of a Patient Care Report • Reports may include subjective statements from the patient. – Cannot include bias or personal opinions • Omissions and errors can result in: – Errors in care – Litigation – Job loss Legal Issues of a Patient Care Report • Reports should be: – Complete – Well written – Legible – Professional • Sloppy documentation implies sloppy care! Confidentiality and HIPAA • Health Insurance Portability and Accountability Act (HIPAA) – Protects patient privacy – Permits disclosure for treatment, payment, and operations Special HIPAA Circumstances • In some cases, patient information must be shared, such as: – Births – Deaths – Disease – Some injury cases – Abuse Purposes of Documentation • The PCR is a record of: – The patient’s condition upon arrival – The care provided – Any changes in the patient’s condition – Condition on arrival Minimum Requirements and Billing • To ensure timely billing: – Document procedures performed. – Obtain insurance codes. – Obtain medical necessity signature. – Document reason patient needed care. EMS Research • Many states now require EMS agencies to submit data to their state EMS office. – Patient care data collection can improve EMS system as a whole. • NEMSIS stores standardized EMS data from each individual state. – The goal of NEMSIS is to define EMS care. Incident Review and Quality Assurance • EMS reports may be requested for medical audits and other educational activities. – Run reviews may occur. • Always accurately document skills attempted and performed with patient care. Types of Patient Care Reports • Most EMS reports are electronic. • Can be easily shared between facilities, personnel, and databases • Improves continuity and efficiency of care Courtesy of Inspironix • Advances evidencebased practice • There are many types of EMS report designs. – In some, narrative sections have been replaced. • Regardless of the form, obtain the proper information. Courtesy of PennCare Types of Patient Care Reports Types of Patient Care Reports • Benefits of electronic reporting: – Ease of data collection and merging – Decrease in errors • Obstacles: – Cost – Technology can be unreliable Documentation for Every EMS Call • Every call requires documentation. • Minimum data set – Standard items documented on every call • Run data • Patient data Documentation for Every EMS Call • PCR should contain: – Changes in patient’s condition • Service treatments may be scheduled or unexpected. Courtesy of Rhonda Beck – Objective observations – Treatments – Effects of treatments Transfer of Care • Document in whose care you left the patient. – Avoids allegations of abandonment – Some agencies require nurse or physician signatures. – Required when you transfer a patient to another agency Care Prior to Arrival • EMD may direct caller to provide care prior to arrival. – Off-duty providers and lay personnel may also provide care. • Document each situation appropriately. Refusal of Care Reporting • Competent, adult patients have the right to refuse care. – Know and understand patient rights. • The patient should know: – His or her current situation – Consequences of refusal of care Refusal of Care Reporting • Information must be: – – – – Given in a language the patient understands Documented on the PCR Witnessed by an observer Initialed and signed by the patient Refusal of Care Reporting • The refusal documentation should clearly show: – The process you went through – How the process is documented – Who witnessed the process Refusal of Care Reporting • Unresponsive patients may be treated under implied consent. • Be familiar with individual state laws related to consent. – Confirm every effort is made to ensure patient’s best interests. Refusal of Care Reporting • If you disagree with a refusal, know the next steps. – Document all contacted parties on PCR. • You must have a witness to the refusal. • Evaluate the patient’s mental status. Refusal of Care Reporting • Remind patient he or she can call EMS later. • Document everything! – Including care you intended to provide • Propose alternate methods of care. – Patients may agree to some treatments and refuse others. Workplace Injury and Illness Documentation • OSHA guidelines require workplace injuries to be logged. – Companies may require additional documentation. – Document precautions taken and protective gear worn Special Circumstances • Multiple-casualty incident (MCI) – Be familiar with triage tags. • Occupational exposure reports – Used if barrier device fails – Know state requirements. • Abuse and neglect cases – Supply as much detail as possible. – Be objective. • Physician's arrival – Physicians may have authority to interject when they arrive on scene. Special Circumstances • Mutual aid services, including: – Helicopters – Specialized rescue teams • Unusual occurrences, such as: – Retraining devices – Severe weather • Follow policy of medical director in special circumstances. • Controlled substances – Paramedics are responsible for security and accountability. PCR Narrative • The PCR contains: – Check boxes – Narrative • Narrative should be: – Detailed – Accurate and complete – Specific PCR Narrative • Know your agency’s preferred narrative method. • Chronological order PCR Narrative • SOAP method – Documents various aspects of the patient care encounter PCR Narrative • CHARTE method – Similar to an EMS assessment PCR Narrative • Body systems/parts approach – A head-to-toe approach • Use one reporting method consistently. – Proper grammar and spelling are essential. – Consider carrying a reference guide. PCR Narrative • Include: – Pertinent negatives – Spoken accounts • Indicate who made the statement. • Use quotation marks around the exact statement. Elements of a Properly Written Report • Information should be comprehensive and concise. – Complete all sections, even if not applicable to call. • Handwritten reports should be: – Legible – Written in ink – Neat and easy to read Elements of a Properly Written Report • Respect patient privacy. • Complete in a timely manner. – Set aside time to neatly complete forms • A record should be left with the patient. – “Drop” or “transfer reports” may used. Elements of a Properly Written Report • A call is incomplete until documentation is processed. • PCRs should not contain: – Jargon – Slang – Personal opinions – Libel • Review your report before submission. • PCRs should be: – Complete – Accurate – Well-written • Written reports reflect on the paramedic. The Effects of Poor Documentation • Can adversely affect patient care • Has legal implications • Affects paramedic’s reputation • Paperwork and reports are essential. – Seek help if needed. Errors and Falsification • Avoid errors. – If they occur, know how to address them. • If a revision must be made: – Note the date and time of revision. – Include purpose for correction. – Never discard the original. Errors and Falsification • Only the person who wrote the report can revise it. • Routine reviews are necessary. • Follow protocol for making corrections. • The PCR is a legal document. Errors and Falsification • Most electronic systems allow for revision. • Addendums and supplemental narratives may be needed. – Follow your service’s policies. • Billing information may be needed. Errors and Falsification • Always be honest and thorough in your documentation. • Lost reports have huge legal implications. – Ensure reports are complete and turned in on time. – Do not keep copies of your reports. Documenting Incident Times • Keeping good time records is essential. – Know which times to track, including time of: • Call • Dispatch • Medication administration – Use military time. Medical Terminology • Use medical terminology correctly. • Learn accepted terms and abbreviations. – Know slang used by your agency. • A wide vocabulary demonstrates competency. Medical Terminology • Components of a word include: – Prefix • Generally describes location or intensity – Suffix • Usually indicates procedure, condition, disease, or part of speech – Root word • Conveys essential meaning; frequently a body part Medical Abbreviations • Can be useful – Use approved abbreviations. • Incorrect or inappropriate abbreviations can have negative impacts. • Accuracy, neatness, and completeness reflect professional writing style. Summary • Each emergency call must be accompanied by a complete formal written report as a vital component of emergency medical care and continuity of patient care. • A written report should be complete, wellwritten, legible, and professional. • Reports may be used in legal proceedings. Summary • HIPAA was designed to protect a person's health information to ensure that it is only disclosed when necessary. • The PCR may be handwritten or electronically written. It must include a checklist and narrative portion and be objective, accurate, and neat. Summary • If a patient refuses care, you must obtain vital signs and a complete history, fully inform the patient of the situation, involve medical control if needed, and thoroughly document the situation. • There are special situations that may require filling out different or additional forms. Be familiar with your state’s requirements. Summary • There are many methods for writing the narrative in your patient care report. Learn the method used by your system. • Complete the patient care report directly after the call. • Any correction to a PCR must include the date, time, and purpose of the correction and have a single line placed through the error with the correct information written next to it. Summary • Falsifying information on the PCR may result in suspension and/or revocation of certification or license. • Inaccurate or poor documentation might lead to inappropriate patient care and may be detrimental to the EMS professional. • Use proper terminology and medical abbreviations in all reports. Credits • Chapter opener: © Mark C. Ide • Backgrounds: Green – Courtesy of Rhonda Beck; Blue – Courtesy of Rhonda Beck; Lime – © Photodisc; Purple – Jones & Bartlett Learning. Courtesy of MIEMSS • Unless otherwise indicated, all photographs and illustrations are under copyright of Jones & Bartlett Learning, courtesy of Maryland Institute for Emergency Medical Services Systems, or have been provided by the American Academy of Orthopaedic Surgeons.