Chapter 6 Knowledge objectives
Discuss various formats for the narrative portion of the PCR. (pp 218-221)
Chronological order: Telling the narrative in a story format from initial dispatch until the call was completed. SOAP method: Subjective information, Objective information, Assessment, Plan for treatment: Allows you to document various aspects of the patient care encounter. CHARTE method: Chief complaint, History (includes history of event and patient's medical history), Assessment, Treatment, Transport, and Exceptions, Breaks narrative into logical sections similar to those used in patient assessment, Body systems/parts approach. Assessment of each body system is documented from head to toe. May be difficult to apply in EMS or too time-consuming.
Compare handwritten PCRs with electronic PCRs, and discuss the pros and cons of each type. (pp 209-210)
Paper reporting is a duplication of work. Information on paper must be entered into an electronic system. Paper requires storage. Reporting on paper may result in errors. Penmanship and spelling errors can lead to medical errors. You will most likely use a written refusal form when it is necessary to obtain a signature from the patient. Many different companies have created electronic patient care reports (ePCRs). There are a variety of ePCR formats available. Modern data systems incorporate data from various sources, such as multiple facilities, to improve patient care. The result is one comprehensive record of patient care. Electronic documentation systems should be NEMSIS-compliant.
Discuss the implications of the Health Insurance Portability and Accountability Act of 1996 as they relate to documentation. (p 207)
The Health Insurance Portability and Accountability Act (HIPAA) has ramifications related to patient care reporting. Loss of license, criminal, civil suits.
Discuss state and/or local reporting requirements for special circumstances, including workplace injuries and illnesses, multiple casualty incidents, occupational exposures, cases of alleged abuse or neglect, and involvement of on-scene physicians or other agencies. (pp 213-217)
The Occupational Safety and Health Administration (OSHA) guidelines require that workplace injuries must be logged. Document what precautions were taken and what protective equipment was being worn by the person involved. Reporting regulations vary from state to state. Situations that may require specialized forms per your state or local agency include: Multiple-casualty incidents (MCIs). Occupational exposure reports should be completed if a barrier device fails or fails to offer enough protection from body fluids or other toxic or infectious agents. When a physician of any specialty arrives or is present on the scene, the physician may have the authority under local protocol to interject with patient care and give directives. Most protocols require the physician to accompany the patient to the hospital once the physician begins care that is beyond the paramedic's scope.
Discuss the process for documenting refusal of care, including the legal implications. (pp 212-213)
The growth of malpractice lawsuits makes documentation of refusal of care very important. Competent adult patients have the right to refuse medical care or to consent to treatment. A decision to refuse care must be based on the patient's sufficient knowledge of their situation.Your most important job is to ensure the patient is fully informed. The patient must be told in great detail and understand the potential consequences of refusing necessary medical care, including the possibility of death. The information given to the patient must be: Conveyed in a language the person understands, Documented on the PCR, Witnessed by an observer, Initialed and signed by the patient. Consider having medical control talk to the patient. Unresponsive patients may be treated under implied consent. Paramedics should be familiar with the individual state laws. Confirm that every reasonable effort has been made to ensure the patient's welfare and best interests. If a patient has an obvious injury or medical condition that requires immediate medical attention and is refusing care, involve online medical control for further guidance and assistance. If you disagree with the refusal, a protocol or policy should be in place of what the next steps should be. Always politely explain to patients that they have the right to change their minds and call EMS again later.
Identify the information required in a PCR, including standard items that must be documented for every emergency call. (pp 210-211).
The minimum data set is the mandatory clinical assessment standard information that must be documented on every call. Set by Medicare and Medicaid, Per the National Highway Traffic Safety Administration (NHTSA), For the purpose of the national data system, The minimum data set is divided into run data and patient data. Run data consist of: Incident times, Locations, Responding units, Crew member names of those working at the incident, Patient data include basic patient information collected on the PCR, such as: Chief complaint, Level of consciousness (according to the AVPU [Awake and alert, responsive to Verbal stimuli, responsive to Pain, Unresponsive] scale) or mental status, Vital signs, Assessment, Patient demographics (age, sex, ethnic background), The PCR should document: Objective observations of the scene (living conditions, MOI, other areas of concern), Treatments provided, Effects of treatments, Changes in patient's condition during the emergency call. Depending on the type of transport, service treatments may need to be differentiated between scheduled and unexpected. An example of a scheduled treatment is a transfer transport. Unexpected treatments resulted from changes in a patient's condition.
Describe the purposes of documentation. (pp 207-209)
Continuity of care: The PCR serves as a record of: The patient's condition upon your arrival at the scene, The care that was provided, Any changes in the patient's condition en route, Condition on arrival at the hospital, The PCR should be accurate and clear to ensure better patient care at the hospital. Minimum requirements and billing. PCR writing must be accurate and complete for billing and administration purposes. For complete and accurate revenue recovery, you must ensure: Procedures performed are documented. Medical necessity signatures are obtained (where required). Reason the patient needed to be transported by ambulance is documented. Inaccurate or incomplete documentation delays billing processing. Your agency may require additional billing paperwork.
Discuss the consequences of intentional falsification of documentation. (p 225)
Do not: Erase information, Scribble through errors, Use correction fluid, Use correction tape. Remember, the PCR is a legal document. Do not falsify. you could get in trouble and loss of license.
Discuss why it is essential that documentation be accurate, legible, and professional. (pp 222-224).
Documentation accuracy depends on all information being complete and precise: Incident times, Narrative information, Checkboxes. Complete all sections of the PCR, even if a section was not applicable to the call. Leaving the boxes blank may raise questions about the completeness of the report. Handwritten reports should be: Legible, Written in ink, Neat and easy to read, Reports should not be contaminated with any liquids found in the field. Place all completed reports in a secure location that protects the patient's privacy agreed upon by you and your partner. A PCR needs to be completed in a timely manner. If multiple calls are responded to without accurately completing PCRs before proceeding to the next call, errors in documentation can occur. Many paramedics: Use assessment cards during calls to take notes, Use the electrocardiographic (ECG) monitor to note times and vital signs, Complete the PCR after the call rather than on the way to the hospital, Some type of written record must always be left with the patient. A drop report or transfer report is a single-page, abbreviated form used as a memory aid during an EMS call. Leave a copy of a drop report or transfer report with a nurse or physician at the hospital if a PCR report cannot be completed. Some states require that copies of written reports (or electronic records) be supplied to the receiving facility or hospital within a specific time frame. All PCRs should be free of the following: Jargon, Slang, Personal opinions. Be certain that your documentation is not libelous. Libel: Writing a false statement that could be harmful to a person's current or future reputation. Only true and accurate statements should be documented. If quotes by bystanders or statements made by the patient are used, be sure to: Indicate who made them. Place the exact words in quotation marks on the report. Carefully review all reports before submitting them to the receiving medical facility and EMS agency. Review PCR for: Completeness, Accuracy, Grammar, Spelling, Proper use of medical terminology and abbreviations. Written reports reflect on the paramedic. A call is considered incomplete until the documentation has been processed.
Explain the procedure to follow should an error occur during or after creating a PCR. (pp 224-225)
If a revision or correction must be made to a PCR: Note the date and time of the revised report. Include the purpose for writing the revision or making the correction. Never discard or destroy the original PCR. Only the person who wrote the original report can revise it. Additions or notations added by others after the completion of the report may raise questions about: The authenticity of the report. The confidentiality practices of your agency.
Discuss the process for documenting transfer of care and care before arrival. (pp 211-212)
It is important to document in whose care the patient was left to avoid allegations of abandonment. Some agencies may require nurse or physician signatures to verify that the patient was transferred properly. You may need to document transfer of care when you hand over the patient to another agency, such as an air medical team. Care prior to arrival. More emergency dispatch centers are shifting to a system called emergency medical dispatch (EMD). EMD allows the dispatcher to select the appropriate units to respond and provide directions to the caller for medical care and medication administration over the phone. When you encounter an EMD, it is important to: Obtain information from the patient or caller as to what care has been provided prior to your arrival, Document your findings. An example of what an EMD center might do is to prescribe aspirin to a caller experiencing chest pain. Correct documentation will ensure the patient does not receive the same medication again. Off-duty health care providers and/or laypeople may provide emergency care prior to EMS arrival. Include the following information in your report: Bystander's procedures with specific notations that care was provided prior to your arrival
Explain the legal implications of the patient care report (PCR). (p 207)
Reports may include subjective statements from the patient but cannot include any personal bias or opinions a paramedic may have regarding the patient. PCRs that are poorly written or inappropriately documented could have adverse implications for patient care and for a paramedic's career. Reports should be complete, well written, legible, professional, and the sole source of information about the call. The Health Insurance Portability and Accountability Act (HIPAA) has ramifications related to patient care reporting.
Discuss why it is important to accurately document incident times. (p 226)
The role of timekeeper falls to dispatchers. Paramedics must also keep track of time during documentation of an incident. Compare times with the dispatchers to ensure: Accuracy and proper timekeeping. That yours and your dispatcher's clocks are synchronized. Discrepancies could lead to controversy in the courtroom. The following incident times are crucial to track: Time of call: Time when the call for help is placed or requested. Time of dispatch: Time when call is toned or alerted for a response. Time of arrival at the scene: Time when EMS unit arrives on scene. Time with patient: Time recorded when patient contact is made. Time of medication administration: Time when medications are administered for adherence to protocols and patient's response. Time of medical procedure: Time when a procedure is conducted on the patient. Time of departure from scene: Time recorded when EMS unit leaves the scene. Time of arrival at medical facility: Time when EMS arrives at the medical facility if the patient is transported. Time of transfer of care: Time when care was transferred to another health care professional at the receiving facility if the patient was transported. Time back in service: Time when EMS unit and crew are ready for return to service. Times are kept in military units to avoid confusion.