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Prehospital Documentation. Westchester County Department of Emergency Services. Objectives. Identify the communication and documentation considerations for EMT’s, EMT/I’s and Paramedics. I want YOU to write a great PCR!. Objectives. Required Data and “why” it’s required
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Prehospital Documentation Westchester County Department of Emergency Services www.westchestergov.com
Objectives • Identify the communication and documentation considerations for EMT’s, EMT/I’s and Paramedics I want YOU towrite a great PCR! www.westchestergov.com
Objectives • Required Data and “why” it’s required • The Do’s and the Don’ts • Types of Forms • Reporting Errors Identify the following: www.westchestergov.com
First Things First…. www.westchestergov.com
Baseline Information • Patient Information • Chief complaint • LOC or mental status • Vital signs www.westchestergov.com
Non Patient Care Information ActivationTime • Time EMS dispatched • Time EMS enroute • Time EMS arrived at scene • Time EMS unit left scene • Time EMS unit arrived at hospital • Time patient care was transferred Travel Time Scene Time www.westchestergov.com
Problems….. • Information recorded incorrectly or left out • write down what did or did not happen • steps taken to correct situation • Falsifying information www.westchestergov.com
If You Make a Mistake…. ------------------ • Draw line through error • Initial and date • Write correct info next to it • May add note with correct info • Do not erase or use correction fluid www.westchestergov.com
Examples of Data Collection • Written form • Computerized www.westchestergov.com
Good documentation reduces: • Litigation • Complaints • Therefore reduces overall risk to the EMS agency, profession, and YOU! www.westchestergov.com
QA & Research • Better ways and methods for patient care • Protocols get changed www.westchestergov.com
QA & Research • Potential problems identified • Best practices identified www.westchestergov.com
PCR Writing – THE ACT! www.westchestergov.com
Why Write a PCR? • Prehospital care report serves six functions: • Continuity of care • Legal documentation • Education • Administrative • Research • Evaluation and quality improvement www.westchestergov.com
Remember……… • Write clearly. • Be objective. • Be accurate. • If you didn’t write it, you didn’t do it. www.westchestergov.com
Remember……… • Don’t pre-judge • What’s the worse that could be going on • Be without bias or prejudice • Chronic patients (Regulars) • Wipe the slate clean www.westchestergov.com
Remember……… • State things concisely. • Use short succinct sentences. • K.I.S.S. • Avoid long winded statements. • Abbreviations (Accepted list). www.westchestergov.com
PCR’s Must Be…. • Legible • All in the same time frame • Clear, not vague • Easy to read • Accurate • Truthful www.westchestergov.com
VITAL VISION • Never record falsely, exaggerate, or make up data • Incorrect spelling, grammar, and punctuation can be misleading, and makes you look uneducated. • Objective information should be stated in a factual manner www.westchestergov.com
Things to Think About…… • Avoid/Hyphen- (minus/negative) • Semicolon; Connect related statements instead of using “Patient states” • Colon: A colon can be used instead of “is” www.westchestergov.com
The 4 “P’s” • Protection • Providers • Patient • Profession www.westchestergov.com
Profession • Data • Quality Improvement • Risk Management • Research www.westchestergov.com
Rule #1 “DO NO HARM” • Know your protocols • Not sure? Speak to Medical Control • Be objective with your treatment • You never know it all. • Rule #2 “USE COMMON SENSE” www.westchestergov.com
You are not judge and jury. • Try to do an assessment. • Inform patient of ramifications. • Must be an informed refusal. • If they are: suicidal, have impaired judgment from drugs/alcohol..They have to be transported. • Minors can’t refuse to go, contact Medical Control. www.westchestergov.com
Get a signed refusal, witnessed preferably by someone other than your partner • Document, document, document,……. • Cancelled, unfounded, left before arrival etc. Document, document, ….. www.westchestergov.com
“You are going to wait for hours in the E.D. before you get seen.” • “An ambulance is going to cost you $$$$” • “Oh, you don’t want to go, okay see ya” • “They wont do anything for you” • “Someone could be dying while you’re tying us up with your bull #&^%” www.westchestergov.com
“This could be related to your heart, it would be a good idea if you get checked out” • “You bent the steering wheel with your chest, there is serious potential for internal injuries” • “You know your family isn’t going to leave you alone unless you go” www.westchestergov.com
Patient • Document what is found at the scene • Document patients condition • Provide subsequent providers with information to continue care www.westchestergov.com
Scene Assessment • “Food rotting on counter tops” • “Apartment cold, heat turned off” • “Refrigerator empty” • “Large pile of newspapers and mail” • “Lives alone unable to get out of bed” • “On the floor for 24 hrs, lg urine stain” www.westchestergov.com
Condition • “Appeared in poor hygiene” • “Incontinent of old urine and feces” • “Lethargic prior to O2 and warming” • “Talking to relatives not there” • “Bradycardia” www.westchestergov.com
The Continuum • Medications • Allergies • Family contacts • Findings/Treatment/Changes • Written Run Report www.westchestergov.com
The Major Malfunction… • Chief Complaint ; “I have chest pain”, “I’m dizzy”, “I can’t breath” What the patient c/o. • If unable to communicate ; Call nature (Man down), (Female collapsed) Use common sense judgment if it’s an unknown. • Came in as an unknown , friend states pt. drank a fifth of whiskey. www.westchestergov.com
Other examples of Subjective • Prior level of function • Lifestyle/home situation, scene survey • History from patient and witnesses • Major complaints • Emotions or attitudes • Goals • Response to treatment www.westchestergov.com
Patient, Patient, Patient! Subjective should be brief and to the point. It is acceptable to use “Patient” the 1st time, after that it’s assumed, unless otherwise stated, that the information in this section came from the patient www.westchestergov.com
Check Please! • Put your narrative in chronological order with past medical history, history of present illness/injury, and changes as they occur. • It makes your report easier to read and make sense. • Do it the same way, EVERY TIME! www.westchestergov.com
The Patient Says…. • Quoting can be the most appropriate method of conveying subjective information. • Verbs States, describes, denies, indicates, c/o. • Denial: “I don’t need to go to the hospital.” • Abusive language: “Keep your F#^%( hands off of me!” www.westchestergov.com
Don’t Go It Alone….. • All of the following information was taken from the patient’s daughter: Lives with daughter and daughter’s husband. • Per wife: “He hasn’t been feeling well for several days.” www.westchestergov.com
Objective / Observations • Measurements performed by the EMT. • Observations by the EMT. • Compared results from treatment. • Primary and Secondary surveys. www.westchestergov.com
When I Look at the Patient I See…. • State of consciousness: A V P U , grimaces to pain, moans to voice, answers questions but is sleepy. • General Appearance: Thin, Obese, Pink, warm, and dry, unkempt…….. • Ataxic gait. • Grip strength weaker on left. • Breath sounds: Clear to auscultation. (CTA). www.westchestergov.com
Assessment • Summary of the patients major problems. • Your sixth sense of what's going on. • Your impression. • Gives a reference point for others. www.westchestergov.com
Examples ….. • Chest pain, r/o M.I. • Acute abdominal pain, r/o etiology. • Acute exacerbation of COPD. • Respiratory arrest, 2° to exacerbation of asthma. • Multi-system Trauma. www.westchestergov.com
Examples ….. • Your written note must justify your treatment. • If you omitted treatment make it clear why. • If it’s not a standing order, Medical Control must be documented and orders received. • Who gave you the orders to treat or withhold Rx. www.westchestergov.com
P L A N of care • Patient’s treatment plan (What you did) • Treatment progression • Plans for assessment and reassessment • Destination • Equipment used • Medications used • Transfer of care • Involvement of other agencies www.westchestergov.com
Subjective • Don’t list irrelevant info. Info should demonstrate need for an ambulance. • Chief complaint, brief and to the point. • Rate pain on Borg Scale. • Avoid documenting chronic complaints. • Changes in mentation or function. www.westchestergov.com
Objective • Show baseline assessment. • Document changes. • Take vital signs, Q-15 min. if stable, Q-10 or less if unstable. At least two sets needed to determine stability. • Re-evaluate patient at least once document change or no change. • Be careful in reporting mental status. www.westchestergov.com
Assessment • Suspected problem. • R/O or R/I conditions you are treating for or strongly suspect. • If unsure describe what you see. www.westchestergov.com
Plan • Treatment make it match the S, O, and A • Appropriate destination • If your agency bills for service: Medicare and Medicaid will audit and demand return of money www.westchestergov.com
RMA • Document assessment findings and care given or attempted. • Have the patient sign the form. • Have a witness sign the form. (Not Partner). • Include a statement that you explained the consequences of refusing care to the patient. www.westchestergov.com
Reportable Issues • Be familiar with required reporting in Westchester County, OSHA and your Agency. • Gun shot wounds (crime scene). • Animal bites. • Infectious disease exposure. • Suspected physical or sexual abuse. • Elder or Child abuse. • Multiple casualty incidents. www.westchestergov.com
Reporting • Child, elderly, and disabled. • Mandated reporters. • Anonymous. • Follow up. www.westchestergov.com