Documentation on EMS Charts

Report
Documentation /
EMSCHARTS
What is documentation?
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A permanent legal document which
provides a comprehensive account of
information about the individual’s health
care status.
Why document?
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Clinical
Legal document which you may have to defend
in court one day, years from incident
Data and statistics
Medical record which must be treated
confidentially, as defined by HIPPA regulations
Education
Quality Management
Guidelines
If it is not written down, it was not done.
 If it was not done, do not write it down.
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Characteristics of Strong
Documentation
Complete
 Clear
 Concise
 Accurate (including spelling)
 Objective
 Timely
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Objective vs. subjective
Objective- intended to be unbiased
 Subjective- usually based on fact, but it is
someone’s interpretation of a fact
Ex: a. The patient was in a lot of pain.
b. The patient had mid-sternal chest
pain which radiated into his back 8/10,
sharp, consistent, negative increase in
pain on palpation.
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Approaches to Narrative (CHART
System)
CHART- Chief Complaint, History,
Assessment, Rx(Treatment), Transport
 Other options: SOAP (Subjective findings,
Objective findings, Assessment, Plan)
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Chief complaint and history (C,H)What you are told
Chief Complaint
 History of Present Illness: OPQRST
 Past Medical History: SAMPLE
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What is a chief complaint?
“Reason EMS has been called, usually recorded
in patient’s own words”
 “Some cases the patient’s chief complaint is
different from the reason EMS was called”
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Source: Emergency Medical Technician EMT in
Action, 2nd Edition, Barbara Aehlert, page 306,
Published by McGraw-Hill, New York, NY, 2011
Assessment (A)- What you
see/feel/hear
Trauma
-pt. appearance, surroundings, position
-head, nose, eyes, ear, throat
-neck
-chest
-abdomen, pelvis
-extremities
 Cardiopulmonary
-pt. appearance, surroundings, position
-neck- jugular veins, trach deviation
-chest – lung sounds, respiratory rate
-extremities- edema, pms
-other- oxygen sat level
 AMS
-pt. appearance, surroundings, position
-mental status (AVPU, orientation, memory, LOC?)
-pupils
-trauma assess
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(Rx,Transport)- What you did
What was done for the patient?
 How was patient moved to stretcher? To
ambulance?
 How did the patient respond?
 Improvement or deteriorating condition
during transport?
 Where was patient brought? Who
assumed care?
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Principles of Writing the Narrative
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Paint a picture
Try to be chronological
Include pertinent negatives
Describe, don’t conclude i.e. “patient was involved in MVA where he
had damage to rear of vehicle” vs. “patient was rear-ended”
Record important observations on scene- i.e. damage to car,
presence of weapons, pill bottles
Only use standard abbreviations
Include changes in pt. condition after treatment/during transport
Identify the source of information
Check spelling/grammar
Do not document interventions by medics
Documenting RMA’s
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More is necessary
High-risk Refusals
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Abdominal Pain
Chest Pain
Electrical shock
Poisoning
Pregnancy related complaints
Water-related incidents
Falls >10 ft
Head Injury
Vehicle roll-over
High speed MVA
Auto vs. pedestrian or auto vs. bicyclist
Motorcycle crash speeds >20 MPH
Pediatric patient with medical complaint
Bare Necessities
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Patient name, age, DOB
Hx, Rx, allergies
Two complete sets of vitals (or a good reason why not)
Mental status findings
Physical exam findings
Reason for refusal
Signed refusal form
Advice given by BLS
Acknowledgement that pt understands risks/dangers of
refusal and possible outcomes
Patient was assessed
Trauma: rapid physical assessment,
focused physical assessment, DCAP-BTLS
 6 vitals signs: lung sounds, pulse,
respiratory rate, blood pressure (cap refill
<3 years old), pupils, skin condition
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Back to basics
Respiratory Distress- lung sounds, respiratory
rate, use of accessory muscles
 AMS- normal mental state, how long has patient
been altered, last seen normal, stroke test
 Psych- threaten themselves or others, physically
violent
 Allergic reaction- known allergies, hives,
itchiness, redness, difficulty breathing, meds
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Set up of EMScharts
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Charting by exception
EMSCharts Guidelines
All charts are to be entered within 24
hours of the call
 All PCR’s will be QA’ed within 72 hours
 All PCR’s should be entered at station or in
ambulance
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