Pt care

EMS patient care record

For all dispatched EMS incidents (FE dispatch code), and all Fire incidents (FF dispatch code) in which an Ambulance, Medic, Squad or EMS Supervisor is dispatched, an _____ shall be completed.

Level III Trauma Center

General trauma facility that has the resources and capabilities to provide resuscitation, stabilization, and assessment of trauma patients and can either provide treatment or arrange for appropriate transfer to a Level I/II trauma facility.

Protocols

Guidelines for practices that are used by EMS personnel in a variety of situations within the EMS system.

15 closest appropriate facility acute exacerbation

HFD apparatus will honor diversion requests provided that: 1. The apparatus estimates that it can reach an "open" and appropriate medical facility within ___ minutes transport from the incident location. If there are no "open" facilities within this time frame, the apparatus will be directed to the most appropriate facility, regardless of its diversion status (exception: internal disaster). 2. The patient does not exhibit an uncontrolled problem in the field such as an unmanageable airway, or cardiopulmonary arrest with CPR in progress. Patients with these types of problems will be transported to the ____________. 3. The patient is not suffering from an ________ of a chronic illness which is evaluated and managed by that particular hospital/hospital system which is on diversion.

Acute

Having a rapid and recent onset and a short course.

Emergency Department Saturation

Hospital emergency department resources (bed, equipment, and/or appropriately trained personnel) are fully committed and have no other resources for additional incoming critical or seriously ill patients and acceptance of any additional patients requiring advanced life support would seriously jeopardize the care of other patients in the emergency department.

ICU Saturation

Hospital intensive care resources are fully committed and have no other resources available for additional patients requiring intensive care. The emergency department can handle minor illnesses not likely to require ICU admission.

Internal Disaster

Hospitals cannot receive patients due to a physical plant breakdown (e.g. fire, bomb threat, power outage, etc.). For situations in which a hospital has advance knowledge that it will need to divert due to an Internal Disaster, hospitals have been asked to notify the Base Station, as well as EMS Command in advance.

medical

ICU saturation refers to the hospital's ability to care for seriously and critically ill ______ patients.

method of restraint, the position of the restraints and the reason for restraining the patient

If it is necessary to restrain a patient to protect the patient from injury, document the events leading to restraint in the HFD patient record. Patient care comes first, then document on the patient care record the _________, the __________and the __________________.

ALL

In ___ cases, a copy of the patient care record will be provided to the hospital prior to the unit leaving the hospital property. Patient care records are still to be completed and given to the hospital during periods of resource management.

immediate EMS Supervisor

In all cases when dispatched to a hospital Emergency Department, HFD members should contact their ___________ to apprise him/her of the situation.

Schedule II drugs

In order to carry and administer controlled substances (i.e. narcotics), it is required to comply with the Federal Government's daily accountability regulations for ________ drugs.

higher EMS certification

In situations where one member is utilized by the department in a _______________ level, that member is responsible for the complete and accurate documentation of the record.

provide the Base Station with a reason the patient will be transported to the original hospital destination requesting diversion.

In the event the intended hospital destination has requested diversion (and that diversion request applies to the patient/condition) the member will advise the patient and agree on an "open" hospital, or _______________________.

reason

Inform hospital personnel who assume responsibility for the patient's care of the_____ for restraining the patient.

Priority 3

Non-emergent transport. Base Station will not give verbal report to receiving hospital. If the patient would benefit from an advanced hospital notification, specifically request the Base Station personnel to inform the hospital

EMS Supervisor

Notify an _____ whenever LifeFlight is requested.

Baseline Assessment

Scene safety, rapid assessment of emergency scene and determination of need for more resources, Airway (with C-Spine protection, if indicated), Breathing, Circulation, and Disability (Neurological Status), identification of chief complaint and initial vital signs.

Hospital Administration

Senior hospital administrative personnel, not assigned to patient care duties in the emergency department, who are responsible for hospital operations at the time of the diversion request.

Standing Orders

Strictly defined written orders for actions, techniques, or drug administration that may be implemented before communication has been established with the physician providing on-line medical direction.

Objective Data

What you saw . . . What you found (Mechanism of Injury)...

Subjective Data

What you were told by . . .

alternative hospital

When a Trauma Center hospital is requesting diversion, seriously injured patients should be taken to an ________.

Base Station's recommendation

When all Trauma Centers of a specific level (e.g. Level I/II) are on diversion, choose hospital destination based on ___________.

scope of practice

When communication with the Base Station fails or is not possible, firefighters are expected to provide care to the patient according to the patient's needs in accordance with fire department policies, training, and ________ as recognized by HFD.

equally

When members hold similar EMS certifications, members are ____ responsible for complete and accurate documentation of the record.

Psychiatric Patient Saturation

When the hospital emergency and/or inpatient psychiatric resources are fully committed and the facility cannot accept any further acute psychiatric patients.

in-charge paramedic

When there is a change in the _______, the Controlled Substances Accountability Form shall be completed according to the current Controlled Substances Accountability Guideline.

Neonate

"Newly born", up to one hour of age.

TRUE

*Not all patients meeting Level I/II Trauma Center criteria need helicopter transport. *Not all patients in need of helicopter transport meet Level I/II Trauma Center criteria

Credentialed

A Houston Firefighter certified or licensed by the State of Texas as an EMT or EMT-Paramedic who is also specifically authorized by the City of Houston EMS Physician Director to provide their respective level of care in accordance with the delegated practice of medicine authority of the Texas Medical Practice Act and these guidelines.

EMS Apparatus Paramedic

A credentialed paramedic assigned to an EMS Apparatus company as part of the paramedic rotation program or the paramedic officer program.

Appropriate Facility

A hospital facility with staffing, equipment and services to care for the patient (e.g. pediatric patients with severe respiratory distress should be transported to a facility with a pediatric department and pediatric intensive care unit).

Emancipated Minor

A legal term for a person age 16 through 17 who is married, a member of the armed services, or living apart from their parents and who is entitled to make their own medical care decisions

Minor

A legal term. A person less than 18 years of age, unless emancipated.

Advanced Life Support (ALS) Unit

A medic or squad unit staffed with at least one credentialed paramedic and one credentialed EMT which provides advanced levels of patient care such as invasive techniques in addition to the basic measures provided by BLS personnel.

Chronic medical problem

A medical condition of any duration, for which the patient is receiving care from a medical professional or is appropriately self-treating.

Capacity to Refuse Care

A patient ,at least 18 years of age, who is capable of making an informed decision will be considered to have capacity to refuse care only if they demonstrate they are oriented to person, place and time; AND can recite back the nature of their medical condition, the risks and benefits of the proposed care/transportation AND the risks of refusing the proposed care/transportation AND is making a reasoned health care decision.

EMS Witnessed Arrest

A patient who goes into cardiac arrest while in the presence of HFD personnel

Witnessed Arrest

A patient who was seen or heard by bystanders (non-HFD personnel) to collapse or become unconscious and was found to be without a pulse or breathing.

Return of Spontaneous Circulation (ROSC)

A return of a palpable pulse (including a transient return) at any point during the resuscitative efforts.

Medical Decision Making Capacity

A state of being in which a person is oriented to person, place, time, circumstance and is able to demonstrate/verbalize an understanding of their medical problem, and potential consequences of refusing or receiving treatment.

#1 Rule : Holder Rule (as promoted by former Assistant Fire Chief Dennis Holder, HFD 1957-1995)

A. "Treat patients and their families as if they are a member of your own family."

Assessment

WHAT DOES THE A STAND FOR IN S.O.A.P.?

Infant

Age one hour up to one year.

a patient was not found

All members are to fully document and describe the events of their dispatched incident, even when __________. An explanation for why an individual for whom EMS was requested is not 'a patient' is required.

public.

All personnel are to operate and conduct themselves in the best interest of the ______.

Form 1106

All units who have contacted the Base Station and initiated a Form ______ shall contact the Base Station and close out their Form _____ before returning to service.

the equipment available.

An EMS Apparatus paramedic shall function as a credentialed paramedic within the limits of ______________

Basic Life Support unit

An EMS apparatus is considered a ________________ even if staffed with a credentialed paramedic.

Basic Life Support (BLS) Unit

An apparatus capable of providing patient transport and basic life support such as airway, oxygen, CPR, bandaging, spinal precautions, etc. in which the staffing standard, in all cases possible, will be two credentialed EMT's. For BLS Ambulances, Texas State EMS Rules require two credentialed EMT's as staffing.

EMS Apparatus

An apparatus, not utilized for patient transport, in which the staffing standard, in all cases possible, will be two credentialed EMT's (e.g. engine, ladder).

Acute emergency medical problem

An injury or symptom of a medical problem (pain, difficulty breathing, rash, etc.), which is recent or has never been evaluated/treated by a medical professional.

Resuscitation

Any effort, including basic and advanced life support procedures, used to restore cardiopulmonary functions.

Restraints

Any mechanism used to physically confine a patient including soft composite dressing, tape, leathers or hand cuffs which are wrapped and secured at the wrist(s) and/or ankle(s) and/or chest and/or lower extremities.

Patient

Any person who is convinced they have an acute emergency medical problem or an exacerbation of a chronic medical problem; or whom a competent EMT would identify as having a medical problem in need of treatment or evaluation

EMS Supervisor

Any unit having problems or conflicts with communications shall contact an ________.

station computer

Any unit without a laptop computer to complete the ePCR shall utilize the ePCR software on a _______ to complete the record according to the requirements stated

2

Assess the patient's circulation (checking pulses in the feet and wrists) every __ minutes, or as frequently as time permits, while the patient is restrained.

Controlled Substances Accountability Form

At the beginning of each shift, the___________ Form shall be completed according to the current Controlled Substances Accountability Guideline.

ICU saturation.

Avoid bringing chest pain, difficulty breathing, elderly patients with abdominal pain, etc., to the hospitals on _____________

Objective data

WHAT DOES THE O STAND FOR IN S.O.A.P.?

which plan/protocol you are going to follow.

Based on the data collected, document the assessment of the patient's problem and ___________.

Defibrillator (LifePak, A.E.D., etc.), Radio, Oxygen and airway equipment, Primary Medical Kit and Suction.

Basic equipment, "D.R.O.P.S." includes

1. The closest hospital is on diversion due to an internal disaster (i.e., power failure, bomb scare, etc.). 2. A second hospital (open) is nearly as close (i.e., the major medical center hospitals example: CPR in progress - 3 of 4 equally close hospitals are all open. One is closed due to ICU saturation - take the patient to one of the completely open hospitals).

CPR Cases: In situations of CPR (non-trauma) in progress, patients will be transported to the closest facility regardless of diversion request with two exceptions:

Persistent Ventricular Fibrillation/Tachycardia

Cases of VF/VT that do not resolve with therapy or are characterized by persistent refibrillation (each refibrillation occurs within two to three minutes after the last conversion).

Level I/II Trauma Center

Comprehensive trauma facility capable of providing the most advanced level of care to the victim of major trauma.

air transport

Consider patients for ________ who are severely ill or injured such that the duration of transport time to the hospital is a major factor in the patient's outcome

alpha-charlie 3

Contact the Base Station ,channel _______, for all patient transports as part of emergency ambulance routing.

ability to breathe

Document the presence of pulses in each extremity and the patient's _______ after restraint is accomplished.

Base Station

During the process of contacting the Base Station for patient transport destination, the ________ will notify the unit if the intended hospital is on diversion. Members will then discuss the hospital's request for diversion with the patient. The Base Station shall be updated on the final destination decision.

History of the Present Illness (HPI)

Each Chief Complaint has a ______ to be pursued

breakdown in system operations

Each occurrence of communication failure will be considered a _________________ and will be reviewed to determine if the occurrence was due to equipment failure or member non-compliance with department policy, procedure or guidelines.

record

Each unit involved in direct patient care shall complete the appropriate _____. For quality assurance and other purposes, other EMS professionals, physicians, nurses, insurance companies, Medicare/Medicaid personnel and the legal community frequently examine these records. They are also used in court cases, grand rounds at the hospitals and reviewed by the Texas Department of State Health Services and the local media.

paramedics

Emergency Transfers (One Emergency Dept. to Another) A. In all cases when dispatched to a hospital Emergency Department, HFD members should contact their immediate EMS Supervisor to apprise him/her of the situation. B. The EMS Supervisor is to review the case to ensure the use of public safety resources is appropriate. If there is any question or doubt, contact the on-line physician via the base station. C. Given approval from the EMS Supervisor, _______ should be able to transfer patients as long as the patient care is within their scope of practice. If the patient is in need of a medication that is not currently on the approved drug list or is on a mechanical device that is not used by the Houston Fire Department, then a nurse or physician familiar with such medications/devices needs to accompany the patient during the transfer.

Priority 1

Emergent transport, immediate life-threatening situation or CPR in progress. Base Station will contact hospital to give a verbal report.

Priority 2

Emergent transport, no CPR. Base Station will contact hospital to give a verbal report. If the patient or hospital would benefit from advance notification, advise Base Station.

Pediatric

Encompasses patients less than 16 years of age or less than 40 kg/88 lbs. Subcategories of 'pediatric' include neonate, infant, child and adolescent

motor vehicle incident scene

Equipment on Each Run A. Bring all basic equipment (see "D.R.O.P.S." below) in close proximity to the patient. B. Basic equipment ("D.R.O.P.S.") includes: Defibrillator (LifePak, A.E.D., etc.), Radio, Oxygen and airway equipment, Primary Medical Kit and Suction. C. The defibrillator and/or the suction may be left in the ambulance at a _______________________, only if it remains in close proximity and there is no prior evidence or communication of possible need for these devices. D. Consider special circumstances in which additional equipment should be immediately carried (such as stretcher/backboard into a high-rise or a C-collar and other packaging devices in an entrapment case). E. ALS units must take all appropriate ALS equipment onto the transporting BLS unit

Plan

WHAT DOES THE P STAND FOR IN S.O.A.P.?

unauthorized individuals or entities

It is the responsibility of all HFD personnel, particularly those members who have direct contact with patient information, to ensure that patient information is kept confidential. Texas law prohibits the disclosure of any patient information to __________ OR _________.

your reassurance and caring.

Keep in mind that, as a firefighter, you provide a public service. Often, the greatest asset provided to the citizens you serve is _______________

O.E.C.

Office of Emergency Communications.

Child

Patient 1 year of age up to age 8 years (the general onset of puberty).

Adult

Patient age 16 or older. For medical consent/legal issues, patient must be 18 unless emancipated

Adolescent

Patient aged 8 up to 16 years of age.

psychiatric evaluation.

Patients who have intentionally overdosed are considered to need ____________.

least delay

Patients with severe trauma generally can only receive definitive treatment for their injuries at a Level I/II Trauma Center. Use the method of transportation that offers the __________ in delivering the patient to a Level I/II Trauma Center.

Base Station Physician

Physician designated by the HFD Physician Director to be responsible for directing patient care in individual cases.

prone position (face down)

Restrain patients in a manner that does not impair circulation, cause choking or aspiration. Do not restrain patients in the ____________.

Subjective data

WHAT DOES THE S STAND FOR IN S.O.A.P.?

Base Station

The Paramedic staffed office which coordinates on-line medical direction and emergency ambulance routing between field EMT's, Paramedics and physicians. This office is staffed 24 hours a day and can relay current hospital requests for ambulance diversion status.

choice of a hospital destination

The _____________ depends upon an understanding of the patient's chief complaint, the urgency of care needed, the specific care needed, hospital diversion status, EMS Resource status, and the patient's routine hospital of choice.

highest ranking member

The ______________ on each apparatus is to ensure the completion and electronic posting of the patient care record in the PCR software for their apparatus. In addition, members shall fully document all aspects of patient care and patient care decisions as per 6.06 Documentation

EMSystems website

The diversion status of each hospital is available on the at the _______________ Base Station. Hospitals are responsible for updating their individual diversion status.

Patient Care Record

The electronic or paper means used to document all information relating to a patient encounter. This includes demographic information, patient complaint information, treatment and therapy information, patient refusals and any other information relevant to the particular patient encounter.

achieve the best possible outcome for children, and all other patients, through mutually beneficial collaboration of health care professionals and family members.

The goal of family-centered care is to __________________. family anxiety.

trauma

Trauma Center Hospitals on ICU saturation generally can still handle __________ patients.

Trauma Saturation (trauma centers only)

Trauma resources are committed and the facility can not accept seriously injured patients because the trauma team is encumbered with trauma patients in the Operating Room, ED or CT scanner.

Unwitnessed Arrest

Unwitnessed Arrest: A patient who was found without a pulse or breathing, and whose collapse was neither seen nor heard.

•Signs / Symptoms •Allergies •Medications •Past illnesses •Last meal, Last Menstrual Cycle •Events leading up to this event

WHAT DOES S.A.M.P.L.E. STAND FOR?

Plan

_____: All interventions performed: C-collar / spinal immobilization, AED, CPR, intubation, I.V. therapy, medications, evaluation of the therapies performed and on-going monitoring noting changes in the patient's status including notations on the patient's condition on arrival at the ED.

Helicopter

______ transportation should be considered only when EMS personnel feel that the advantages of its use outweigh the disadvantages for a particular situation.

Physical restraints

_______ prevent a confused, disoriented, intoxicated, violent, psychotic or suicidal patient from self injury or injury to others

Documentation

__________ provides a record of what you did or did not do while additionally serving as a Medical Record and a Legal Document.

Family-centered care

_____________ is a systematic approach to building collaborative relationships between health care professionals and families that uses those relationships to assist in providing quality EMS care and promoting overall community health and safety. B. It acknowledges and uses the family's knowledge of their family member's condition and their skills in communicating with and caring for their family member. It emphasizes the importance of keeping family members informed about their loved one's condition, prognosis, and treatment. C. Prehospital family-centered care encourages family presence during procedures and embraces family-centered care principles during on-scene treatment, transport, and transition of care to in-hospital health care providers.

Controlled Substance

a DEA scheduled medication which has been declared by federal or state law to be used or distributed only under a physician's order. The basis for control and regulation is the danger of addiction, abuse, physical and mental harm (including death), the trafficking by illegal means, and the dangers from actions of those who have used the substances. Controlled substances are subject to daily accountability regulations.

Physical Exam (CHAMPION)

•Cardiac (Heart Sounds, Pulses) •HEENT •Abdomen •Mental Status •Pulmonary (Breath Sounds, Work of Breathing) •Integumentary (Skin) •Other (Vital Signs, Diagnostics) •Neuro (Strength, Sensation)