Prehospital Documentation

1. Prehospital Documentation Amy Gutman MD Amy.Gutman72@gmail.com

2. Why is it important? Patient Care Reports (PCRs) serve as: 1. The patient care record (continuity of care) 2. A legal document 3. A billing resource 4. An administrative tool

3. The PCR as a Record of Patient Care • Documents continuity of care • Describes patient’s condition before & after contact with EMS • Establishes provider credibility & competency

4. The PCR “The patient care report serves as the ‘official record’ of the care you provided… The purpose of the report 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 • There is no exception made for non-transports, patients that are gone on arrival, disregards, or situations in which there was minimal contact with a person and/or no treatment was administered • Local standards on documentation may be viewed under Ohio EMS Recordkeeping Requirements: • OAC 4766-6-01 • ORC 119.03 • ORC 4766.03

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? • Described in patient’s own words, expressed in quotations if possible • EMT should indicate the reason the 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 while describing their problem? • 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 And regularity Skin Temperature Oxygen saturation CO2 If possible Monitor strip Vital Signs

17. Treatment • All interventions • Includes: • Interventions by bystanders/ family members prior to your arrival • Your interventions • Pt’s 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 was transferred to unit • 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 administered 10 LPM via NRB due to decreased pulse ox from 99% RA to 90% RA” Also: Changes in condition upon arrival at ED Document name & title of the person care was 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 will be reviewed Document everything that was done, & if a standard treatment was not done, why not? “Exceptions”

23. Exceptions: Trauma Patients • Trauma triage legislation in the state of Ohio requires EMS providers to document if patient met 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” • SSubjective • OObservations • AAssessment • PPlan

25. Abbreviations • Abandon home-grown abbreviations • DRT, BFN • Use only accepted abbreviations • Spelling counts; If a jury looks at your chart & it is full of errors, they may conclude that you are as sloppy at patient care as you are at documentation

26. 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 and spinal immobilization

27. 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

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

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

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

31. Witnessed Arrest & Bystander CPR • “Yes” or “No” • Bystander CPR sometimes noted in HPI as well, and may include if AED was used on scene • Important for tracking community involvement & outcomes • May help in receiving public health grants for education

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

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

34. ROSC • A perfusing BP, sustained HR, spontaneous respirations prior to transferring the patient to the ED • After that, it’s my job to determine if the “20 minute” Utstein criteria time frame present, & the outcome

35. 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 of patient at time of transfer Times: Dispatched to Scene Arrival On Scene Time on Scene Departure to Hospital Arrival to Hospital Important Points to Document

36. Bystanders • Include name, level of training & license number of ANY non FD medical personnel who assist during assessment or patient care

37. 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”

38. Refusals • NEVER accepted by any pediatric patient or adult with AMS • Document attempts to convince patient that transport is recommended • Include potential consequences explained to patient • All refusals must be signed, including signatures by the patient/ guardian/ Power of Attorney, provider & witness • If police or an adult family member not available, your partner’s signature is appropriate

39. DNRs • Does patient have a DNR? • Patient can change mind at any time • Include statement regarding the DNR in your report • What was the date • Who signed it • Physically present at scene • DNR does not equal “Do Not Treat”

40. 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 was found face-down under her bed-sheets, cold, cyanotic, with vomitus noted in oropharynx”

41. Helpful Hints: • Protect Patient Confidentiality • Always follow HIPAA guidelines • Falsification of the EMS report equals fraud • Your patient care report CAN be subpoenaed without you being there to defend it

42. Of Course… • If it was not documented, it never happened • Always proofread

43. Questions?