Chapter 20

1. Chapter 20 Record

2. Overview • The Record • Principles of Documentation • Special Incident Reports • The EMT as a Good Citizen • Multiple-Casualty Incident • Patient Refusal Documentation

3. The Record • Problem-Oriented Medical Record Keeping (POMR) • Universal standard of documentation • Uses a problem or diagnosis as an index • Patient’s chief complaint is basis for EMT care

5. The Record • Functions of the record • Prehospital PCR • Can speak for the patient • Can describe scene where patient was found

6. The Record • Functions of the record: Quality improvement • Administrative purposes tied to patient care • Continuous quality improvement process • Peer review process • Call review process

7. The Record • Functions of the record: Research • Used to improve EMT practice • Identifies what works and what does not work • Helps identify ineffective treatments • Helps underpin particular practice • Suggests ways to improve care

8. The Record • Functions of the record: Administrative purposes • Not directly tied to patient’s care • Billing information • Information for other reports

9. The Record • Functions of the record: Legal document • Used in court of law • EMT must depend on PCR when testifying

11. The Record • Minimum data sets • Administrative data set • Medical data set • State and federal governments

12. The Record • Format for documentation: • Open format • Closed format • Hybrid format

13. The Record • Format for documentation: SOAP charting S = Subjective O = Objective A = Assessment P = Plan

14. The Record • Format for documentation: Extended charting methods • SOAPIE • CHART

15. The Record • Format for documentation: CHEATED charting C = Chief complaint H = History E = Examination A = Assessment T = Treatment E = Evaluation D = Disposition

16. Stop and Review • List four functions of the PCR. • List the elements of the acronym CHEATED.

17. Principles of Documentation • Be objective • Document only patient statements that clarify condition • Document all care • Be timely • Complete PCRs at point of transfer

18. Principles of Documentation • Documentation standards • The record must be readable • Use accurate abbreviations if used at all

19. Principles of Documentation • Documentation standards: Errors and corrections • Cross-outs • Do not use white correction fluid or black out • Initial last point • Add initials, date, and time to end of PCR • Documentation can be reopened when needed

21. Principles of Documentation • Documentation standards: Legibility • Write clearly • May use block printing • Use black ink

22. Special Incident Reports • Special incident report—for documentation of specific incidents • Injury to EMT • Infectious disease exposure • Equipment failure

23. Special Incident Report • Injury to EMT • Report injury immediately • Report serves as a basis for claim

24. Special Incident Report • Infectious disease exposure • Report EMT exposure • Give report to infection control officer • OSHA regulation • Follow local protocols

25. Special Incident Report • Equipment failure • File report when equipment fails on a call • Return report to a supervisor • Reports may be legal evidence

26. The EMT as Good Citizen • Patient care is always the EMT’s first responsibility • Other responsibilities • Report suspected abuse • Written testimony (affidavit) • Testifying in court • Agency procedure

27. Multiple-Casualty Incident • Half a dozen to a hundred or more patients • Triage tags

28. Patient Refusal Documentation • When patient refuses care • Document his decision-making • Patient refusal form • Consult EMS supervisor • Contact ED physician • Witness • Standardized refusal of medical assistance

29. Stop and Review • Describe how to correct an error in the record. • List several reasons to write a special incident report.