Documentation: Professionalism, INTEGRITY & funding

1. Documentation:Professionalism, INTEGRITY & funding Amy Gutman MD EMS Medical Director prehospitalmd@gmail.com

2. Who Cares About Documentation? • CYA! • Data drives research; research drives outcomes • CQI & research show you how good your department is, & highlight room for improvement • You are professionals – your documentation should reflect this professionalism • Not to be bitchy…but poor care (or the perception of poor care) reflects badly on me. You work under my license & at my discretion. Don’t piss me off.

3. But one Chart Doesn’t Change Patient Care, Does It?

4. What Did Data Do For SFD? • Drove change to ETCO2-driven appropriate ventilation vs “hypo” or “hyper” ventilation • Proved that EMTs & EMT-Ps apply high level technical & physiological information to improve cardiac arrest outcomes • Improved ROSC from 22% to 38% & survival from 4% to 11% from ALL cardiac arrests in one year • Changes in Policy: • Cardiac Arrest • Vehicle & Equipment Sanitation • No Hauls • Death-In-Field • Skills Tracking • Personnel Distribution

5. What Can Data Do For your fd? • Justify personnel • Defend increased number of response vehicles & transport units • Show responsibility to the patient, as well as overall improved quality of care • Move towards greatness • Identity strengths & weaknesses • Document and publish successes

6. Notebooks • Every PCR generates 30-50 data points • Every arrest provides an additional 16 data points • Missing data weakens patient care, CQI, billing & research

7. Charting Methods • It does not matter which methods you use, as long as the documentation is thorough, complete & professional • Yes…spelling & punctuation count

8. DCHARTE & Soap D Dispatch Time / Type C CC H History A Assessment R Rx at Scene T Treatment Enroute E Exemptions S Subjective OObservations A Assessment PPlan

9. SAMPLE – OPQRST O Onset P Provokes Q Quality R Radiation S Severity (1-10 scale) T Time S SSX AAllergies MMeds PPMH L Last PO intake E Events (i.e. MOI)

10. General ConceptsAKA “Don’t Overload the Truck”

11. Key areas of emt liability • Bad Refusals • Failure to consider “competency” • Failure to document • Negligence • Ordinary negligence vs. Gross negligence • Abandonment • Transfer of care • Failure to document • Patient Care Issues • Airway • Spinal Immobilization • Equipment Failure • NV status

12. NEGLIGENCE elements • Duty: • “Obligatory conduct owed by a person to another person.” • In tort law, duty is a legally sanctioned obligation, the breach of which results in liability • Breach: • “Failure to perform a duty owed to another; a failure to exercise that care which a reasonable, prudent man would exercise under similar circumstances.” • Damages: • “For actual harm resulting from the defendant’s wrongful act or omission” • Proximate Cause: • “Results were caused by one’s conduct or omission.” Barron’s Law Dictionary, Fifth Edition, 2003

13. Keep accurate times • Dispatched to Scene • Arrival On Scene • BLS & ALS • Actions On Scene • i.e. Medications • i.e. Time to shock • Time on Scene • Departure to Hospital • Arrival to Hospital

14. Abbreviations • No home-grown abbreviations • DRT • DFU • BFN • LOL

15. SPELLING COUNTS • If a jury looks at a chart full of basic errors, they will conclude that you are as sloppy at patient care as you are at documentation

16. Bystanders & transfers • Include name, level of training, license number(s) of ANY medical personnel who have assisted at any point during assessment or patient care • Include initials or badge number person writing the narrative • When transferring care, document name/ position who accepts patient

17. 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, mottled, cyanotic, with vomitus noted in oropharynx”

18. Charting

19. Chief Complaint • Why did patient call 911? • Pt’s words in quotes • “Upon arrival found 54 yo F on couch. Pt reports “feeling like someone is sitting on my chest.” • vs • “Called to house for possible heart attack”

20. HPI • Descriptive narrative telling a story from onset of symptoms, bystander involvement, prehospital treatments to time of transfer

21. History Obtained from someone other than patient • Indicate why • Language barrier • Disability • Document who provided history • Translator • Family • Friend

22. PMH/ PSH • Past Medical & Surgical • Medical / surgical • Similar presentations: “The last time my chest hurt this much, I went to the cath lab” • Allergies • Drug & reaction • Medications • Write “BP med” if that is what pt states • Be as thorough as possible

23. Good emts aren’t Helped By bad Documentation

24. SAD BUT TRUE EXAMPLES • “Arrived on scene, pt sick to her stomack, said she ate some food that may be bad. V/S normal. Placed pt in POC and transported to ER.” • “On scene found patient drunk. He’s a regular who always gets drunk. He called for EMS to avoid going to jail. He stinks bad. We turned him over to PO.” • “Caled 4 medcal raisins. Patience in floore. She wus sikk. She puuked on floore. Blud wus in the puok. She didn’t waunt us so we lift.”

25. Complete Vitals: BP RR (effort / number) O2 sat / capnography HR Temperature Repeat serially Note changes in pt status If you do something…what happened? Vitals are vital

26. Dispatch • Computer Aided Dispatch • Best Friend vs Worst Enemy • Only as good as the dispatchers & dispatch tools • Nature & Type of call • Updates Enroute • CPR in progress • Police on scene

27. MVC HPI HPI should emphasize mechanism of injury What Is missing from above HPI?

28. MVC HPI • Types of vehicles involved • Principal Direction of Force (PDOF) • Speed of both vehicles • Description of Damage/ Intrusion • Number of Patients • Position of Patients • Death/ Serious Injury in Passenger • Restraints • Ambulatory at Scene

29. Trauma HPI

30. Assessment • Your “impression” rather than a diagnosis • Observations & subjective information • “51 yo M with CP & ST elevations in II, III, AvF” • “Provider Impression” • Essential for billing • Proof that pt had an ALS assessment & treatment

31. Treatment • All interventions • Includes: • Bystander interventions prior to your arrival • Your interventions • Any positive or negative response to treatment • “Pt placed on 100% NRB. Sat increased from 88 to 97%, RR decreased from 34 to 18/min”

32. Examples of “Treatments/ Interventions”

33. Other Treatments & Interventions

34. Transportation & triage • Methods of transfer to unit & to hospital • Seated • Supine • C spine immobilization • Any treatment initiated or continued while en-route • “VS reassessed q 15mins • O2 at 10 LPM NRB due to decreased O2 sat from 99% RA to 90% RA”

35. Document name & title of the person to which patient care was transferred Reason for Triage: Closest facility Trauma Triage Patient request If “Requesting” & “Transport” hospitals are different, document why Transportation & triage

36. Exceptions TO STANDARD OF CARE • All treatments must be consistent with OEMS protocols • Document everything that was done • If a standard treatment was not done, why not? • Any “exception” from norm, i.e. “Patient refused ASA due to known allergy” • CYA - Justifies why you did or did not do something • Keeps CQI & Medical Director off your back

37. Trauma Patients • Trauma triage legislation requires providers to document if pt met criteria for transportation to a trauma center • Try to justify using at least 2 criteria: • “Pt unconscious following front-impact MVC. Transported to a Level 1 trauma center due to bilateral femur fractures.”

38. Refusals • NEVER from pediatrics, or intoxicated/ confused adults • Thoroughly document effort to provide informed consent including potential complications (use & write the word “death”) • All refusals must be signed, including signatures by the patient/ guardian/ power of attorney, provider & witness • If police or family not available, your partner’s signature is adequate • Refusals are the most common prehospital documents to show up in court – pay extra attention to spelling, grammar, punctuation, signatures, times & dates

39. DNRs / MOLST • Patient can change mind at any time • “Patient requested EMS to disregard DNR” • Include statement regarding DNR in PCR • Date document signed & who signed it • If the paperwork is not physically present it does not exist

40. Cardiac arrest documentation • Reportable to state & national registries • Affects policy, national standards & patient outcomes

41. Date / Time Incident Number Accepting Hospital Age / DOB Gender / Race Past Medical History Down Time Time to Patient Contact Time On Scene Witnessed Arrest Bystander CPR Initial & Serial Rhythms Initial & Serial Vitals Ventilation rate Initial & Serial ETCO2 Any Interventions (meds, defibrillation) ROSC HPI Narrative Utstein CA Data Collection

42. BASICS XXXXX xx xx John Smith 111-11-1111

43. Good Narratives tell “Stories”

44. Should have “4 Point” intubation confirmation in narrative • ETT visualized passing through cords • ETCO2 confirmation • BL breath sounds ausculated • No epigastric sounds

45. Sloppy & Incomplete This patient SURVIVED a cardiac arrest…wouldn’t it have been nice to know why?

46. Time to Patient Contact • NOT time “on scene” • If BLS unit arrived first, document their interventions • Time on scene also important to document; national standards are <10 mins

47. Witnessed Arrest & Bystander CPR • “Yes” or “No” • Was AED was used on scene? • Important for tracking community involvement & outcomes • May help in receiving public health grants for education

48. Vitals are VITAL! • If patient has no vitals or spontaneous respirations, document: • Rate at which you are ventilating patient • ETCO2 • Rate you are performing chest compressions • New CPR Guidelines & ongoing research into the “best” resuscitation strategies • ETCO2 is not just a number, it may be a predictor of outcome

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

50. FYI • NV status before & after splinting & spinal immobilization • Loose/ missing teeth prior to intubation • Subjective “feelings” are assessments • Protect patient confidentiality • Falsification of EMS reports equals fraud • Spelling, grammar & punctuation count – this is a legal document and reflects your professionalism