DOCUMENTATION



documentation

Emphasis on documentation has increased dramatically, paralleled by sophistication of patient care and rise in medical litigation. Emphasis on documentation can also be attributed to increased quality assessment/improvement, educational levels, and awareness of EMS professionals.

Documentation should be practiced just like any other technical skill. Refining a few definitions and procedures will help avoid pitfalls, enhance the delivery of patient care, and reduce the risk of litigation. Documentation procedures -

Provide a record of scene information that may not be available from any other source.

Provide continuity of care from one healthcare professional to another.

Provide medicolegal evidence.

Reveal any significant changes in the patient’s condition.

Provide an internal tool for statistics, budgeting, and quality assessment/improvement.

Reveal problems with record-keeping procedures.

Procedure

1. Collect all patient demographic information (e.g., name, age, sex, address).

2. Complete all blanks and check all pertinent boxes on the call report form.

3. Begin the narrative by documenting the patient’s level of consciousness (LOC), age, and how he or she appears initially. “20 y.o. male found supine on living room floor, conscious and alert.”

4. Document patient’s chief complaint. This should be in the patient’s own words and included in quotation marks, if possible.

5. Document history of present illness. This should be given in chronological sequence and should include the time of onset, frequency, location, quantity, character of the problem, setting, and anything that aggravates or alleviates the problem.

6. Document review systems and physical assessment findings, including any pertinent positives or negatives. This should be a head-to-toe assessment, when indicated.

7. Document any significant past medical history, including surgeries, hospitalizations, illnesses, or injuries.

8. Document allergies and current medications.

9. Document treatment procedures, who performed the procedures, and the patient’s response or lack of response to treatment. Include times.

10. Document vital signs and orders, with times.

11. Attach all EKG strips documented with date, time, lead, and patient’s name.

12. Complete Glasgow Coma Scale, with times.

13. Obtain receiving nurse’s and doctor’s signature as needed.

14. Leave copy of report with patient’s chart.

Definitions

Anatomic figure, injury identification is an anterior and posterior figure located on the call report form. It should be used to mark and label the patient’s injuries.

Chief complaint (CC) is a brief sentence or statement describing the patient’s reason for seeking medical attention. It should be the patient’s own words if possible (e.g., “My chest hurts” or “I can’t catch my breath”).

Demographic data include name, age, date of birth, address, occupation, and nearest relative.

History of present illness/injury (HPI) documents events or complaints associated with the patient’s deviation from normal health. This should correlate with the reason the person is seeking medical attention only for his or her current medical problem, not past problems (e.g., “While painting last night around 10:00 PM, I began having this dull pain in my chest” or “I lost control of my motorcycle and slid about 50 feet down the roadway”).

Past medical history (PMH) documents any significant past medical or traumatic illnesses that relate to the patient’s present illness or injury. These data should include hospitalizations, surgeries, illnesses, or injuries.

Pertinent negative is the absence of a sign or symptom that helps to substantiate or identify a patient’s condition. For example, a patient with a suspected dislocated hip usually has decreased range of motion; if the patient has good range of motion, this should be documented.

Pertinent positive is the presence of a sign or symptom that helps to substantiate or identify a patient’s condition. For example, if a patient falls and complains of leg pain, an obvious bend of the midshaft lower leg is a positive sign of injury and should be documented.

Physician orders are physician-directed advanced life support (ALS) or basic life support (BLS) treatment orders.

Response to treatment is the patient’s response or lack of response to the care that was rendered.

Review of systems (ROS)/physical assessment are two separate categories that should be combined in the EMS field assessment. The review of systems is a head-to-toe review of all complaints system-by-system. The physical assessment is a head-to-toe, hands-on examination. These two should be combined for EMS documentation into the complaints and physical findings.

Treatment is the care rendered to the patient.

Additional documentation tips

1. Do not blacken through any documentation; draw one line through it and place your initials beside it.

2. Use correct spelling.

3. If normal protocol or standard of care was not followed, document why.

4. Document any delays or problems responding, gaining access, or transporting the patient. Include an explanation of the problem and the length of the delay.

5. Document any domestic problems that might have arisen.

6. Use a supplement sheet when necessary. The narrative does not have to be squeezed into a small area on the call report form.

7. Use approved medical abbreviations.

8. Write legibly, clearly, and concisely.

9. A patient who presents with trauma and has experienced a significant mechanism of injury should have a documented head-to-toe physical assessment, not just of areas of major complaint.

10. Complete the form as soon as possible; it enhances accuracy.

11. REMEMBER, IF IT WAS NOT DOCUMENTED, IT WAS NOT DONE!

Documentation by Call Type

The following lists are specific pieces of information that may be necessary for complete and accurate documentation. This information is not in prioritized order. These lists indicate suggested items that should be included in your documentation.

Car Crash

Patient location in auto

Seatbelt or shoulder harness usage

Loss of consciousness

Velocity of accident

Type of accident (head-on, roll-over)

Type of vehicle damage

Patient trapped or pinned

Delay in extrication

Patient ejected from vehicle

Patient ambulatory at scene

Coma

Sign or history of trauma

History of diabetes or seizure

Drug or alcohol ingestion

Last seen conscious by whom and when

Position found

Scene survey

Pupils

Response to painful or verbal stimulus

GCS

Diabetes

Level of consciousness

Insulin-dependent or oral hypoglycemics

Last meal

Amount of exercise

Last insulin injection and how much

Any recent illnesses

Gradual or rapid onset of symptoms

Kussmaul breathing

Alcohol or other drug use

Trauma

Level of consciousness

Type of accident

Ambulatory after accident

Head-to-toe assessment

Special circumstances

Scene survey

Overdose

Level of consciousness

Whether overdose was witnessed or not

Medication or substance ingested

Amount ingested

Time of overdose or best approximation

Any associated alcohol or drug consumption

Prior overdose or suicide attempts

Patient admission of intent to harm self

Police notification

Chest Pain

Activity at time of pain onset

Radiation

Pain on movement

Onset (gradual or sudden)

Breath sounds (presence, quality, and quantity)

Dyspnea

Nausea and/or vomiting

Diaphoresis

Jugular venous distention

Peripheral edema

Pain character (sharp, dull)

For any pain, PQRST format can be used

Pain on scale 1-10

Gunshot wound

Number of wounds

Location of wounds

Type of weapon (handgun, rifle, or shotgun)

Patient’s position at time of shooting

Perpetrator’s position at time of shooting

How many shots heard

Head-to-toe assessment

Note caliber of weapon, if it can be confirmed

Amount of external hemorrhage noted

Police notification

No transport call

Clear documentation

Patient demographic information

Patient informed of consequences of not being transported

Methods used to encourage patient to accept treatment/transportation

Alcohol or other drug usage

Level of consciousness

Patient’s reason for contacting EMS

Individual responsible for contacting EMS, if not the patient

Vital signs

Physical exam

Cancellation en route noted (e.g., police, fire, dispatch)

Patient’s cooperation with your attempt to deliver care and transport

Signature of patient

Signature of witnesses

Pediatric

Level of consciousness (crying, uninterested)

Parent recognition

Consolable

Fontanelles (full, flat, or sunken)

Child’s weight

Skin condition

Finger grasp

Response to pain

Fever

Length of illness

Medications or treatments administered

Respiratory distress

Level of consciousness

Skin color and temperature

Amount of distress (mild, moderate, or severe)

Audible respiratory sounds (wheezes, rales, rhonchi)

Onset of distress (gradual or sudden)

Activity at time of onset

Cardiac history

COPD history

Breath sounds (present, absent, wheezes, rales)

Seizure

Level of consciousness

History of seizures

History of alcohol or other drug usage

History of diabetes

Sign or history of injury

Number of seizures

Duration of seizures

Motor activity observed during seizure (e.g., where began and spread)

Medication history (i.e., takes seizure or diabetic medications regularly)

Pupils

Breath sounds

Head-to-toe assessment

Cardiac history

Pregnancy

Last menstrual period

Estimated due date (if known)

Number of pregnancies (gravida)

Number of pregnancies carried to term (para)

Prenatal care history (none, some, continuous)

Complications with this pregnancy

Complications with other pregnancies

Water broke

Back pain

Urge to push

Vaginal discharge

Multiple births

Type of pain

Duration of pain

Regularity of pain

Interval between pains

Progress during transport

Stab wounds

Number of wounds

Location of wounds

Amount of external hemorrhage noted

Patient’s position at time of stabbing

Perpetrator’s position and knife angle at time of stabbing

Head-to-toe assessment

Scene survey & Police notification

Documentation Checklist

Procedure Possible Points

points awarded

|Obtain demographic information |1 | |

|Clearly define chief complaint |1 | |

|Note initial level of consciousness |1 | |

|Define location/presentation |1 | |

|Obtain history of present illness |1 | |

|Perform complete physical assessment |1 | |

|Note pertinent positives |1 | |

|Note pertinent negatives |1 | |

|Note pertinent past medical history |1 | |

|Document allergies |1 | |

|List current medications |1 | |

|Record treatment |1 | |

|Record response to treatment |1 | |

|Place EKG strip. (ALS services only) |1 | |

|Document orders |1 | |

|Document times |1 | |

|Record vital signs |1 | |

|Complete Glasgow Coma Scale |1 | |

|Completed Trauma Score (if indicated) |1 | |

|Obtain appropriate signatures at receiving facility |1 | |

| | | |

| Total |20 | |

|Points | | |

| | | |

COMMENTS:____________________________________________________________

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PAPERWRK.DOC

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