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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