Prehospital Documentation

1. Prehospital Documentation Amy Gutman MD prehospitalmd@gmail.com / amy.gutman@hahv.org

2. Why Is It Important? Patient Care Reports (PCRs) serve as: • Patient care record (continuity of care) • Legal document • Billing resource • Administrative tool

3. The PCR as a Record of Patient Care • Continuity of care • Describes condition before & after EMS contact • Establishes provider credibility & competency

4. The PCR “Serves as the ‘official record’ of the care you provided… The purpose of the PCR is to provide the reader with a ‘picture’ of the continuum of care that was provided to the patient from the arrival of first responders to the transfer of care in the hospital. It becomes your ‘substituted’ memory.” Courtesy : Good Documentation is Your Best Defense: Steve Worth, Esquire

5. Legal Document • A report must be generated for any patient contact • No exception for non-transports, patients “missing” on arrival, or situations in which there was minimal contact &/or no treatment provided • Local standards on documentation may be viewed under NY EMS website

6. Billing Tool • Poorly written, incomplete or missing PCRs are billing obstacles

7. Administrative Tool • Establishes need for EMS services in a particular area • Protects your job

8. Narratives

9. DCHARTE D = Dispatch C = CC H = History A = Assessment R = Rx at scene T= Treatment Enroute E = Exemptions

10. Dispatch • What is the nature of the call? • Updates provided enroute • i.e. CPR in progress, police on scene

11. Chief Complaint • Why did patient call 911? • Or who called & why? • Described in patient’s own words, quotations if possible • EMS should indicate reason patient was unable to speak • Document who provided history

12. Examples • Upon arrival found 54 year old female seated on couch. Patient reports “pressure in chest” describes as “feels like someone is sitting on my chest” • Vs • “Possible heart attack”

13. What If Patient Curses? • Quote em! • “My chest f_c_ing hurts.”

14. S SSX A Allergies M Meds P PMH L Last PO intake E Events (i.e. MOI) SAMPLE History

15. SAMPLE – OPQRST • O Onset • P Provokes • Q Quality • R Radiation • S Severity (scale of 1-10) • T Time

16. Blood Pressure Respirations Effort Number Heart rate / regularity Skin Temperature Oxygen saturation CO2 If possible Monitor strip Vital Signs

17. Treatment • All interventions • Includes: • Interventions by bystanders prior to your arrival • Your interventions • Response to treatment • Document telemetry or notification calls as part of treatment

18. Examples of “Treatments/ Interventions”

19. Other Treatments/ Interventions

20. Transportation • Method by which patient transferred • ALS, BLS • Method of transport to hospital • Seated • Supine • C spine immobilization • Emergent (lights & sirens) • Non-Emergent

21. Description of treatment initiated / continued “VS reassessed q 15mins. O2 10 LPM via NRB due to decreased pulse ox from 99% RA to 90% RA” Also: Changes in condition upon ED arrival Document name / title of person care transferred to at ED Transportation

22. Anything that is an “exception” from the norm i.e. “Patient refused aspirin due to known allergy” All treatment must be consistent with protocols Through CQI process, PCRs reviewed Document everything that was done, & if a standard treatment was not done, why not? “Exceptions”

23. Exceptions: Trauma Patients • Principles of trauma triage suggest EMS providers document if patient meets criteria for transportation to a trauma center • i.e. “Patient unconscious following MVC. Transported to a Level 1 trauma center due to bilateral femur fractures”

24. Alternative Methods: “SOAP” • S Subjective • O Observations • A Assessment • P Plan

25. Abbreviations • No home-grown abbreviations • DRT, BFN • Only accepted abbreviations • Spelling counts • If a jury looks at your error-filled chart they may conclude that you are as sloppy at patient care as you are at documentation

27. Pertinent Negatives • Anything you would expect to find during assessment, yet patient denies • i.e. “no diaphoresis” while patient having CP • NV status before / after splinting & spinal immobilization

28. Date/ Time Incident Number Accepting Hospital Age/ DOB Gender Past Medical History Down Time Time to Patient Contact Witnessed Arrest Bystander CPR Initial & Serial Rhythms Initial & Serial Vitals (ventilation rates!) Initial & Serial ETCO2 Any Interventions (meds, defibrillation) ROSC HPI Narrative Utstein OOHCA Documentation

29. Basics A Good Narrative tells a “story”, giving a full picture of the code

30. Down Time • Best estimate based upon “story” received on scene • Quantify as: • <10 mins • 11-15 mins • 16-30 mins • 31-60 mins • > 60/ unk mins

31. Time to Patient Contact • NOT time “on scene” • If another unit arrives first, document their interventions

32. Witnessed Arrest & Bystander CPR • “Yes” or “No” • Bystander CPR can be noted in HPI as well, including if AED used on scene • Tracks community involvement & outcomes • Helps in receiving public health grants for education

33. Vitals are VITAL! • If patient is coding with “no” vitals, document rate at which you are ventilating patient • New CPR Guidelines • Ongoing research • ETCO2 not just a number, it is a predictor of outcome

34. EtCO2 is a cardiac output indicator • The lower the CO, the lower the EtCO2 • If EtCO2 <10mmHg after 20 minutes of CPR, resuscitation success rate is <1% • Higher EtCO2 = effective resuscitation

35. Rhythm • Initial • Changes with any intervention • Final rhythm at presentation to ED

36. ROSC • Perfusing BP, sustained HR, spontaneous respirations prior to transferring patient to the ED • After that, it’s the QA officer’s / medical director job to determine if the “20 minute” Utstein criteria time frame present, & patient outcome

37. NV status before & after splinting & spinal immobilization Loose/ missing teeth prior to intubation Reason for Triage: Closest facility Patient request Trauma Triage Transfer of Care Facility Name of person Title of person Condition at time of transfer Times: Dispatched to scene Arrival on scene Time on scene Departure to hospital Arrival to hospital Important Points to Document

38. Bystanders • Include name, level of training & license number of ANY non-EMS personnel who assist during assessment or management

39. Just The Facts, Please • Avoid name calling, i.e. “frequent flyer” • If an error was made, document what happened & what you did to correct it • Report delays in care, & how it affected treatment: • “Police did not secure the scene for 15 minutes, resulting in a delay of care”

40. Refusals • NEVER accepted by any pediatric patient or adult with AMS / not competent to make decisions • Document attempts to convince patient transport is recommended • Include potential consequences explained to patient • Potential consequences always includes DEATH • All refusals must be signed, including signatures by the patient/ guardian / health care agent, provider & witness • If police or an adult family member not available, your partner’s signature is appropriate

41. DNR / MOLST • DNR/ MOLST? • Competent patient / health care agent can change mind at any time • Include statement regarding DNR / MOLST in your report • ? Date • ? Signed • Physically present at scene • DNR does not equal “Do Not Treat”

42. This Is Not CSI • Unless you’re a medical or forensic specialist don’t make assumptions • i.e. entrance & exit wounds • Explain what was found & how it appeared • “Infant found face-down under bed-sheets, cold, cyanotic, with vomitus noted in oropharynx”

43. Helpful Hints • Protect patient confidentiality • Follow HIPAA guidelines • Falsification of EMS report equals fraud • Any PCR CAN be subpoenaed without you being there to defend it

44. Of Course… • If it was not documented, it never happened • If it was documented…it doesn’t mean it happened • Always proofread

45. Questions?prehospitalmd@gmail.com/ amy.gutman@hahv.org