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UMENTATION

VIEWS: 4 PAGES: 25

									DOCUMENTATION:

     A Necessity of EMS
Objectives
   Explain:
        Who needs a PCR
        Why documentation is necessary
        The core and minimum standards for documentation
        Three methods of EMS documenation
   Relate the preliminary PCR to the digital PCR, explaining the
    purpose and when to use
   Define the standards for:
        Documenting a gross Cranial Nerve exam
        Documenting a Gross Motor exam
        Documenting the Drug Awareness (Drug Recognition) Exam
   Explain when/how to use EMTs to document refusals
Who Needs A PCR?
   Section 1:3 Patient Defined
       A patient shall be defined as:
            Any individual who activates EMS for themselves
            Any individual who identifies themselves as such
            Any individual for whom 9-1-1 is called on their behalf
             for suspected illness or injury
            Any individual with an injury or illness
            Any individual with a medical or traumatic complaint
            Any individual with a new altered level of consciousness

                    But what about alcohol on board?
Assessment of the Intoxicated
Person: Section 2:2
   Perform a physical exam to rule out the
    presence of any sign of trauma
   Assess mental status
   Assess gross motor/sensory function
   Assess gross cranial nerve II-XII function
   Conduct D.A.R. (Drug Awareness
    Recognition) 7-step Process
   Obtain VS
Assessment of the Intoxicated
Person: Section 2:2
   If the patient is
    oriented and the
    following are present:
       Speech slurred but words   These findings indicate low
        are understandable         risk and this person may go
       Horizontal nystagmus may   to jail or home with a sober
        be present
                                   person to watch them.
       Able to ambulate on two
        feet without help
       No MOI, no complaint and
        or signs/symptoms of
        injury or illness
       No other substance
        finding
    Assessment of the Intoxicated
    Person: Section 2:2
   If the patient is
    oriented or altered
    and any of the
    following are                  This person has a higher
    present:                       risk, consult with ED or
       MOI or signs/symptoms      transport.
        of minor injury (such as
        a small abrasion)
       Other substance abuse
        as indicated by the
        D.A.R. Process
       Systolic BP is > 140 or
        < 90
       HR is > 90
Why Document?
   LEGAL
       Avoid lawsuits, negligence, abandonment vs refusals
   COMMUNICATE MEDICAL
    INFORMATION
       ER, PCP, Surgeons
   QUALITY ASSURANCE
       Agency Review, Teaching, Peer Review, Recognition as a
        *Profession*
   STATE REQUIREMENT
The Core of Documentation
   What   did they tell you?
   What   did you see?
   What   is/are the problem(s)?
   What   is/are the solution(s)?
Minimum Standards
   Identifying Information
   What Happened
   Description of Symptoms & Pertinent History
   Pertinent Exam
   Treatment Initiated
   Response to Treatment
   Events During Transport
Description of Documentation
Methods
 PROGRESS NOTE       EMS NOTE             MEDICAL NOTE
    SOAP note        CHART note               DR's note
S= Subjective    C= Call             CC= Chief Complaint
O= Objective     H= History          HPI= Hx of Present Illness
A= Assessment    A= Assessment       PMH= Past Medical Hx
P= Plan          R= Rx (treatment)     -Medical Hx
                 T= Tx (transport)     -Surgical Hx
                                       -Medications
                                       -Allergies
                                       -Social Hx
                                     ROS= Review of Systems
                                     PE= Physical Exam
                                     DDx= Differential Dx
                                     IMPRESSION
                                     PLAN
                                        -Therapeutic
                                        -Diagnostic
                                        -Response to Plan
                                     DISCUSSION
                 Combining the Methods
               Type              PROGRESS NOTE     EMS NOTE             MEDICAL NOTE             The Core of Documentation
             Nickname               SOAP note      CHART note              DR's note
Prior to Arrival                S= Subjective  C= Call              HPI= Hx of Present Illness   What did they Say?
Initial Impression                                                  HPI= Hx of Present Illness   (What did you See?)
Chief Complaint                                 H= History          CC= Chief Complaint
Symptoms of Injury or Illness                                       HPI= Hx of Present Illness
Preceding Events                                                    HPI= Hx of Present Illness
Pertinent History                                                   PMH= Past Medical Hx
Additional History
Missing Symptoms                                                    ROS= Review of Systems
Signs of Injury or Illness      O= Objective    A= Assessment       PE= Physical Exam            What did you See?
Differential Diagnoses          A= Assessment                       DDx= Differential Dx         What is the Problem?
Impression                                                          IMPRESSION
Plan                            P= Plan         R= Rx (treatment)   PLAN                         What is the Solution?
  -Therapeutic                                                        -Therapeutic
  -Diagnostic                                                         -Diagnostic
Response to Plan                                T= Tx (transport)     -Response to Plan
Further Discussion                                                  DISCUSSION
Events and Symptoms
   What Happened?              Pertinent Symptoms
       Prior to EMS                Pertinent Positives
        activation
       Describe accidents          Pertinent Negatives
       OPQRST
Pertinent Positives and
Pertinent Negatives
   Pertinent Positives                   Pertinent Negatives
       Items that exist that                 Items that exclude one of
        support the diagnosis                  the differential diagnoses
       Can be symptoms, signs,               Can be symptoms, signs,
        tests                                  tests, or response to
            i.e. glucometer value),           treatment
       or response to treatment              most often includes
            i.e.  BP &  P after             negative symptoms
             fluid bolus                           i.e. no SOB makes CHF
                                                    unlikely
                                                   i.e. no trauma makes a
                                                    fracture unlikely
Important Past Medical History
Components
   The P in SAMPLE…...              Immunizations?
   Major Medical Hx:                Social Hx:
    cardiac, HTN, DM, CVAs               Alternative drugs
                                          (herbals)
   Surgical Hx:                         Recreational Drugs, EtOH
       past 6 months
                                         Daily Diet
       abdominal surgeries for
                                         Sexual History as
        CC of abdominal pain
                                          pertinent to the chief
       cardiac for CC of chest           complaint, such as the
        pain, SOB                         female of child bearing
       trauma or obstetric for           age who has abdominal
        CC of SOB, CP, DVT                pain
Physical Exam
   PHYSICAL EXAM                         Physical Exam
       Trauma Patient                        Medical Patient
            Initial Impression                    Initial Impression
            Primary Survey and *Key               Primary Survey and
             Interventions*                         *Key Interventions*
             Trauma-Based Secondary
                                                    Medical-Based
         
                                                
             Survey (pertinent
             negatives)                             Secondary
                  VS, LOC                              VS, LOC
                                                        CHEST
                  HEENT
                                                        ABDOMEN
                  CHEST
                                                        EXT
                  ABD
                                                        NEURO
                  PELVIS
                  EXT
Physical Exam
   Physical Exam
       Pertinent Positives
       Pertinent Negatives
       Positives and Negatives
        should relate to the call
       (ie „no flail segments‟ does
        not relate to a stroke unless
        they fell)
Treatment & Transport
   Treatment Initiated       Response to Treatment
       Medications               What they tell you
       Stabilization                  „breathing easier‟
       Transport method               *PAIN SCALE*
                                  What you assess
                                       lung sounds- decreased
                                        rales
                                       patient became
                                        tachycardic
                                  Changes in Treatment
                                       withheld atrovent
                                       gave additional pain
                                        meds
Special Cases
   Refusals                               AMAs
       Include:                               Include:
            Events                                 All Refusal
            Chief Complaint                         Information plus:
            Physical Exam!!!                             Impression
                  Mental Status, VS,                     Call In to ED
                   Head-to-Toe                            Discussion with
                                                           Patient of Risks
            Signature of
             Understanding
            Potential Risks
Special Cases
   CN II-XII                         Drug Recognition
       Include:                       Exam
            Positives/Negatives          Include:
   Gross Motor                                Pupil
                                                movement/reaction
       Include:
                                               Romberg multi-
            Positives/Negatives                task/time test
                                               VS (P + BP)
Items to Avoid
   Opinion Statements “I don‟t think he
    really passed out”
   Judgmental Statements “patient
    obviously drunk”
   Unrecognized Abbreviations
   The terms „alcohol on breath‟, „non-
    cardiac chest pain‟, etc.
Items to Include
   ECG is attached to PCR
       On white copy (permanent record)
       On yellow copy (QA copy)
   Pertinent data
       Pt Name, Times, Dates, PCR#, Mileage
   Face sheet
       If out of normal delivery area
            Such as: Platte Valley, NCMC, North Suburban
Preliminary PCR (or PPCR)
   RETAC Project
   Less than 35% of PCRs are left at the
    hospital within 24 hours of pt delivery
   MVFPD > 90% at all hospitals
       50% are missing necessary information
            Date, address, mileage, pt. name, times, etc.
PPCR
   Leave in ED
       A temporary
        document
   ePCR emailed or
    faxed in when
    completed
PCR Review
   Is it legible?
   Does it follow a pattern?
   Is it accurate?
   Does it meet minimum standards?
   Would you feel comfortable with this as
    your supporting document in court???
Reminders
   John Michael will be coming later this month
    to talk about documentation using the
    narrative section of the ePCRs.
   Dr. Kanowitz will be here to help with the
    review, specifically refusals and using EMTs.
   Any other questions, please let Twink know

								
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