Documentation

1. Documentation

2. Documentation • Purposes • Preserves basic patient information • Records changes in patient condition • Justifies treatment • Allows continuity of care • Satisfies regulatory requirements • Provides data for quality control

3. Documentation • Protection for EMS personnel • Reflection of good patient care

4. Documentation An accurate, complete, legible medical record implies accurate, complete, organized assessment and management

5. Documentation • Characteristics of good medical record • Accurate • Complete • Legible • Free of extraneous information

6. Accurate • Document facts, observations only • Do NOT speculate about patient or incident • Double-check numerical entries • Recheck spellings of: • Persons • Locations • Medical terms

7. Accurate If you make a mistake, document it. It is better to record your own mistakes that for someone else to uncover them.

8. Complete • Include all requested information • If information requested does not apply, note “not applicable” or “N/A” • Include at least two sets of vital signs on every patient • Failure to document implies failure to consider • If you look for something and it isn’t there, document its absence

9. Complete IF IT ISN’T DOCUMENTED, IT WASN’T DONE!

10. Legible • If you cannot read the report, you may be unable to determine what happened • Documents presented in court must “speak for themselves” • If a document cannot be deciphered, the jury has to right to ignore it altogether

11. Legible If the report is sloppy, others will assume that the care was equally sloppy

12. Free of Extraneous Information • Avoid labeling patients (“drunk”, “psych patient”) • Describe the observations you made • Preface comments made by the patient with “per the patient” or “patient stated”

13. Free of Extraneous Information • Record hearsay only if applicable • Do NOT record hearsay as facts • Use quotation marks only if a statement is accurate word-for-word

14. Free of Extraneous Information Avoid interjecting humor The public does not regard EMS as a funny business

15. Documentation • A copy of the report must be left with the patient at the receiving hospital • State law requires this • Patient care has not legally been transferred until the hospital has your written report

16. Documentation • The person who rode with the patient writes the report • All personnel who participated in care should review the report

17. Documentation • If something needs to be corrected, correct it • The sooner an error is corrected, the more credible and reliable the change is • Mark through information so it is still readable • Then write in the new information and initial/date the change

18. Documentation If you have a long report, don’t hesitate to use additional pages

19. Documentation • Avoid stating diagnostic impressions • Report facts and observations • If you must state a diagnostic impression • Do so within the scope of your training • Include the observations that led to the impression

20. Documentation Avoid using “possible” or “?” when the observation would have been obvious to anyone

21. Documentation • Be sure treatments recorded match the mechanism of injury or the diagnostic impression • If something should have been done that was not, state why

22. Documentation • If spaces are provided for documenting times, fill them in carefully • Failing to document times implies lack of concern about the time factor • If you have a prolonged scene time, say why

23. Documentation If you put a monitor on the patient, a hard copy of the EKG should accompany the report

24. Documentation • If a patient complains of pain in a area, state what you found when you examined the area • Failure to record your observations implies that you noted the complaint, but did not investigate it

25. Documentation • On MVCs, report • Type of collision (head-on, roll-over, lateral impact, etc.) • Degree of damage to vehicles • Location of patients • Use of seatbelts

26. Documentation • On falls report: • Where the patient fell from • How far the patient fell • The surface the patient fell onto • Why the patient probably fell

27. Documentation • On head injuries report: • Level of consciousness • Pupillary responses

28. Documentation • On head injuries report: • Presence/absence of: • Discharge from nose and ears • Cervical pain, muscle spasm, tenderness, deformity • Paresthesias • Altered motor function • Altered sensory function

29. Documentation • On chest injuries report: • Position of trachea • Status of neck veins, breath sounds, heart sounds • Presence or absence of • Crepitus • Subcutaneous air • Paradoxical movement of chest wall

30. Documentation • On extremity injuries report: • Distal skin color and temperature • Presence or absence of: • Distal pulses • Motor function • Sensory function

31. Good Documentation is NOT C.Y.A Good Documentation is a Reflection of Good Patient Care

32. Refusals • These can be the most problematic patients • Transport involuntarily- may face allegations of assault, battery or false imprisonment • Leave pt behind-may be accused of negligence or abandonment

33. Refusal policies • Many are inadequate • Some rely on inappropriate criteria • Some are too abbreviated • Some give false sense of security • Laws may vary from one jurisdiction to the next • Essential elements- competence, documentation, and supervision

34. Competence • Well-informed, mentally competent adults have the right to refuse or accept care • This right of refusal is by no means absolute • In a medical emergency, EMS personnel may force a pt. rendered mentally incompetent by illness, injury, or intoxication to accept life-saving care • Challenge-which patient should be presumed incompetent

35. Historically- if pt is aware of person, place and time then they are allowed to refuse care…Don’t make this mistake. • Because an oriented pt may not possess the ability to process information effectively, focus on pt’s comprehension. • Patient should be able to understand the nature of the condition, risks and benefits of proposed treatment, risks and benefits of refusing care.

36. Before accepting a refusal, explain the nature of the emergency and the risks and benefits of treatment and refusal, then ask the patient to explain in their own words what they were told to determine if the understand all three elements.

37. Documentation • This is vital • If a lawsuit arises years after the incident, the documentation will provide the facts as the memories of the involved parties will fade and/or change. • Report should include, at a minimum- physical exam with vital signs, factors affecting pt’s ability to reason (i.e. drugs or alcohol), the treatment offered.

38. Ask the patient to sign a release/refusal form • The supplements the patient care report • Helps show that the patient, not the EMS personnel, made the decision • Ask any witnesses as well to sign this form

39. Refusal/Release form • Must state more than the fact that the pt refused transport • Must indicate that the pt was advised of the suspected medical condition and that they understand the nature of the proposed treatment and potential consequences of refusal • Should be advised and drafted by an attorney and may want to consider including a release – from – liability provision

40. Supervision • Whenever possible medical control should be consulted to supervise a pt’s refusal. • In the case of a lawsuit, a physician’s testimony may support that the filed providers handled the situation correctly.

41. 12 item checklist • 1. physical exam and vital signs • 2. history of event and past medical history including medications • 3. pt or decision-maker is capable of refusing medical care • 4. risks of refusal of care and transport explained • 5. benefits of medical care and transport explained • 6.pt clearly offered medical care and/or transport

42. 7. refusal form prepared, explained, signed, and witnessed • 8. pt confirmed to have understanding of the risks and benefits involved in their decision • 9. pt advised to seek medical attention for complaint • 10. pt advised to call 911 if condition continues or worsens • 11. base consultation occurred according to local policy • 12. supervisor notified if any of the above not accomplished

43. By implementing these standards when it comes to refusal, EMS systems may significantly reduce their liability.