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DOCUMENTATION:

DOCUMENTATION:. A Necessity of EMS. Objectives. Explain: Who needs a PCR Why documentation is necessary The core and minimum standards for documentation Three methods of EMS documenation Relate the preliminary PCR to the digital PCR, explaining the purpose and when to use

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DOCUMENTATION:

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  1. DOCUMENTATION: A Necessity of EMS

  2. Objectives • Explain: • Who needs a PCR • Why documentation is necessary • The core and minimum standards for documentation • Three methods of EMS documenation • Relate the preliminary PCR to the digital PCR, explaining the purpose and when to use • Define the standards for: • Documenting a gross Cranial Nerve exam • Documenting a Gross Motor exam • Documenting the Drug Awareness (Drug Recognition) Exam • Explain when/how to use EMTs to document refusals

  3. Who Needs A PCR? • Section 1:3 Patient Defined • A patient shall be defined as: • Any individual who activates EMS for themselves • Any individual who identifies themselves as such • Any individual for whom 9-1-1 is called on their behalf for suspected illness or injury • Any individual with an injury or illness • Any individual with a medical or traumatic complaint • Any individual with a new altered level of consciousness But what about alcohol on board?

  4. Assessment of the Intoxicated Person: Section 2:2 • Perform a physical exam to rule out the presence of any sign of trauma • Assess mental status • Assess gross motor/sensory function • Assess gross cranial nerve II-XII function • Conduct D.A.R. (Drug Awareness Recognition) 7-step Process • Obtain VS

  5. If the patient is oriented and the following are present: Speech slurred but words are understandable Horizontal nystagmus may be present Able to ambulate on two feet without help No MOI, no complaint and or signs/symptoms of injury or illness No other substance finding These findings indicate low risk and this person may go to jail or home with a sober person to watch them. Assessment of the Intoxicated Person: Section 2:2

  6. If the patient is oriented or altered and any of the following are present: MOI or signs/symptoms of minor injury (such as a small abrasion) Other substance abuse as indicated by the D.A.R. Process Systolic BP is > 140 or < 90 HR is > 90 This person has a higher risk, consult with ED or transport. Assessment of the Intoxicated Person: Section 2:2

  7. Why Document? • LEGAL • Avoid lawsuits, negligence, abandonment vs refusals • COMMUNICATE MEDICAL INFORMATION • ER, PCP, Surgeons • QUALITY ASSURANCE • Agency Review, Teaching, Peer Review, Recognition as a *Profession* • STATE REQUIREMENT

  8. The Core of Documentation • What did they tell you? • What did you see? • What is/are the problem(s)? • What is/are the solution(s)?

  9. Minimum Standards • Identifying Information • What Happened • Description of Symptoms & Pertinent History • Pertinent Exam • Treatment Initiated • Response to Treatment • Events During Transport

  10. Description of Documentation Methods

  11. Combining the Methods

  12. What Happened? Prior to EMS activation Describe accidents OPQRST Pertinent Symptoms Pertinent Positives Pertinent Negatives Events and Symptoms

  13. Pertinent Positives Items that exist that support the diagnosis Can be symptoms, signs, tests i.e. glucometer value), or response to treatment i.e.  BP &  P after fluid bolus Pertinent Negatives Items that exclude one of the differential diagnoses Can be symptoms, signs, tests, or response to treatment most often includes negative symptoms i.e. no SOB makes CHF unlikely i.e. no trauma makes a fracture unlikely Pertinent Positives and Pertinent Negatives

  14. The P in SAMPLE…... Major Medical Hx:cardiac, HTN, DM, CVAs Surgical Hx: past 6 months abdominal surgeries for CC of abdominal pain cardiac for CC of chest pain, SOB trauma or obstetric for CC of SOB, CP, DVT Immunizations? Social Hx: Alternative drugs (herbals) Recreational Drugs, EtOH Daily Diet Sexual History as pertinent to the chief complaint, such as the female of child bearing age who has abdominal pain Important Past Medical History Components

  15. PHYSICAL EXAM Trauma Patient Initial Impression Primary Survey and *Key Interventions* Trauma-Based Secondary Survey (pertinent negatives) VS, LOC HEENT CHEST ABD PELVIS EXT Physical Exam Medical Patient Initial Impression Primary Survey and *Key Interventions* Medical-Based Secondary VS, LOC CHEST ABDOMEN EXT NEURO Physical Exam

  16. Physical Exam Pertinent Positives Pertinent Negatives Positives and Negatives should relate to the call (ie ‘no flail segments’ does not relate to a stroke unless they fell) Physical Exam

  17. Treatment Initiated Medications Stabilization Transport method Response to Treatment What they tell you ‘breathing easier’ *PAIN SCALE* What you assess lung sounds- decreased rales patient became tachycardic Changes in Treatment withheld atrovent gave additional pain meds Treatment & Transport

  18. Refusals Include: Events Chief Complaint Physical Exam!!! Mental Status, VS, Head-to-Toe Signature of Understanding Potential Risks AMAs Include: All Refusal Information plus: Impression Call In to ED Discussion with Patient of Risks Special Cases

  19. CN II-XII Include: Positives/Negatives Gross Motor Include: Positives/Negatives Drug Recognition Exam Include: Pupil movement/reaction Romberg multi-task/time test VS (P + BP) Special Cases

  20. Items to Avoid • Opinion Statements “I don’t think he really passed out” • Judgmental Statements “patient obviously drunk” • Unrecognized Abbreviations • The terms ‘alcohol on breath’, ‘non-cardiac chest pain’, etc.

  21. Items to Include • ECG is attached to PCR • On white copy (permanent record) • On yellow copy (QA copy) • Pertinent data • Pt Name, Times, Dates, PCR#, Mileage • Face sheet • If out of normal delivery area • Such as: Platte Valley, NCMC, North Suburban

  22. Preliminary PCR (or PPCR) • RETAC Project • Less than 35% of PCRs are left at the hospital within 24 hours of pt delivery • MVFPD > 90% at all hospitals • 50% are missing necessary information • Date, address, mileage, pt. name, times, etc.

  23. Leave in ED A temporary document ePCR emailed or faxed in when completed PPCR

  24. PCR Review • Is it legible? • Does it follow a pattern? • Is it accurate? • Does it meet minimum standards? • Would you feel comfortable with this as your supporting document in court???

  25. Reminders • John Michael will be coming later this month to talk about documentation using the narrative section of the ePCRs. • Dr. Kanowitz will be here to help with the review, specifically refusals and using EMTs. • Any other questions, please let Twink know

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