731 - EMS Communication & Documentation PDF

ROMEOVILLE FIRE DEPARTMENT MANUAL 731 CATEGORY 700: EMERGENCY MEDICAL SERVICES POLICY NUMBER TITLE EMS COMMUNICATION & DOCUMENTATION EFFECTIVE 01/01/2013 AUTHORIZED Kent Adams, Fire Chief REVISED 03/18/2018 03/25/2022 PURPOSE To identify the importance of and the processes involved in the communicat...

ROMEOVILLE FIRE DEPARTMENT MANUAL 731 CATEGORY 700: EMERGENCY MEDICAL SERVICES POLICY NUMBER TITLE EMS COMMUNICATION & DOCUMENTATION EFFECTIVE 01/01/2013 AUTHORIZED Kent Adams, Fire Chief REVISED 03/18/2018 03/25/2022 PURPOSE To identify the importance of and the processes involved in the communication and documentation of patient care by members of the Romeoville Fire Department in a way that complies with policies set forth by the Illinois Department of Public Health (IDPH), Edward Hospital Emergency Services System (EHEMSS) and the Romeoville Fire Department so that efficient and forthright care of all patients is the resulting outcome for all patient contacts. PROCEDURE There are five (5) phases of communication that occur during a typical EMS incident: 1) The occurrence or incident 2) Detection for the need of EMS 3) Notification and EMS response 4) EMS arrival & treatment (which includes Medical Control consultation) 5) Preparation of EMS for the next emergency response. There are two types of communication modes: Written (See RFD EMS Training Manual) Verbal (3 modes) Verbal- Utilized on the scene of an EMS incident while communicating with the patient, transferring care to another crew/provider or when transferring care to hospital staff in the emergency room Page 1 of 9 ROMEOVILLE FIRE DEPARTMENT MANUAL Radio- Utilized while enroute to an EMS incident with the Romeoville Dispatch Center, mutual-aid agencies, Romeoville Fire Department (RFD) staff and to receiving hospitals as the need for back-up communications is identified (MERCI) Cellphone- Utilized for communications ranging from patient care reporting to a medical control location, contacting responsible parties involved in the medical refusal process, transmitting cardiac data and communicating with RFD staff. WRITTEN COMMUNICATION Written documentation of an EMS incident serves several important functions. It provides a written & legal record of the incident; it conveys important clinical information from the field to the Emergency Room. This documentation will become part of the patient’s medical records. The written report can also be utilized for: Billing Audits Quality Improvement Studies Billing Information Data Collection Research Legal Defense ePCRs All patient care reports (ePCRs) shall be completed and sent to the Will County server prior to departure from any receiving hospital unless there are extenuating circumstances (MCI) (IDPH Administrative Rule Title 77 Part 515.350). All ePCRs for refusals or lift assists shall be completed and sent to the Will County server prior to the end of any shift (am/pm). All EMS laptops shall be “restarted” each morning using the “Restart” button after clicking the Windows icon located in the lower left corner of the display screen. This action will restart the three services necessary for the Zoll ePCR to function properly. Page 2 of 9 ROMEOVILLE FIRE DEPARTMENT MANUAL When giving mutual-aid to another community scene or change-of-quarters, the CAD dispatch server creates an EMS ePCR. Do not use the “open” pcr when dispatched for subsequent calls in the mutual-aid community as the CAD will create an “on-scene” and “at patient” time that is erroneous. The Paramedic-in-Charge shall contact RFD dispatch to request that a new “ticket” for the call communicating the address, nature of the call and your dispatch time. This will prevent any confusion between the Fire and EMS software Documentation Outline for EMS Reports Chief Complaint: History: Patient complaint – If possible quote the patient directly Symptoms Degree of Distress and/or Pain SAMPLE information as appropriate o Symptoms o Allergies o Medications o Pertinent medical history o Last oral intake, Last menstrual period o Events leading to present condition Mechanism of injury (if applicable) Pertinent scene information Assessment: Level of consciousness C-spine Clearance of SMR (if applicable) Signs of illness and/or injury Vital Signs (Repeat vitals as patient needs present) Trauma Score (if applicable) GCS Page 3 of 9 ROMEOVILLE FIRE DEPARTMENT MANUAL FAST Score (Stroke Care) Blood Sugar Pulse Oximeter 3-Lead EKG interpretation (if applicable) 12-Lead EKG interpretation (if applicable) Treatment: Specific care initiated Patient response to treatment Reaction to Drug Administration Spinal Motion Restriction (if applicable) CMS prior to and after splinting (if applicable) Hospital Contact: Mode of communication (E-bridge Alert, Radio, MERCI) Hospital transported to Refusal Direction/Documentation Narrative Elements for Adult Refusals: A through description of the circumstances of the incident (History) The patient’s condition including: o Chief Complaint o Assessment (Findings) o Level of Consciousness Document the patient’s legal and mental competence to refuse Medical Care Document that RFD personnel informed the patient of: o The nature of the illness or injury o Associated risks o Recommended treatment o Potential consequences of refusing treatment Document that the patient acknowledges and signature Document the approval of Medical Control (log number, ECRN number) Page 4 of 9 ROMEOVILLE FIRE DEPARTMENT MANUAL All refusals shall be completed at the scene where the refusal is obtained to include the patient’s signature and medical control approval if applicable. The balance of the refusal documentation may be completed after returning to the station Once MPR signature forms are completed, the electronic documentation may be completed after returning to the station Narrative Elements for Minor Refusals: Document the key points of an Adult Refusal Document the name of the parent or legal guardian that the RFD personnel spoke with Document the telephone number called when attempting contact Document who is assuming responsibility of the patient and the means of transportation from the scene. Document the name or # of the Medical Control Physician (Not ECRN) who approved the refusal) Narrative Formatting Recommendation The SOAP Format Subjective Data: (includes) Chief Complaint Symptoms Past Medical History Current Medications Allergies Any information that is given by family and/or witness Objective Data: (includes) Physical Finding Physical Exam Diagnostic Test results Page 5 of 9 ROMEOVILLE FIRE DEPARTMENT MANUAL Assessment Data: Paramedic’s clinical impression based on the Subjective and Objective Data Plan of Patient Management: Appropriate SOP that will be followed for patient care & treatment. Outline of Radio Report Name of agency & apparatus identifier Followup from E-bridge notification (Stroke, Cardiac, Sepsis) Age, Sex & Weight (kg) of the patient Level of Consciousness (LOC) Chief Complaint & Paramedic’s Impression (including severity) Mechanism of Injury History: o Symptoms o Allergies o Medications o Past Medical History o Last Oral intake o Events surrounding incident o Last menstrual period o Pertinent positives/negatives Vital Signs: o Pulse Rate (quality & regularity) o Blood Pressure o Respirations (rate, pattern, & depth) o Skin parameters (color, temperature, moisture, & turgor) Clinical Findings: o Assessment findings from review of systems (positive & negative) Page 6 of 9 ROMEOVILLE FIRE DEPARTMENT MANUAL Diagnostic Test results: Vital Signs o Stable  Vitals at least every 15 minutes o Unstable  Every 5 minutes  After every ALS intervention RTS & GCS (or components to calculate scores) FAST Score (if applicable) Treatment given and ETA Narrative Elements for Intubated Patients The need for intubation The presence or absence of a gag reflex The size of the Endotracheal Tube The auscultation of the Epigastrium Auscultation of the Breath Sounds The level of the Endotracheal Tube The use of an Endotracheal Tube restraint device The use of an End Tidal CO2 device The re-evaluation of tube placement, including epigastric and breath sounds, after each patient movement. Document the use of Auto Vent 2000 and settings (tidal volume & rate) that were utilized. Narrative Elements for Ketamine/Versed (Peds) Usage Document the need for Ketamine or Versed per SOP criteria The effects of the medication The use of Benzocaine Spray The successful Endotracheal Tube placement (See narrative elements for Intubated Patients too.) The use of Versed as a Post Intubation Sedation and reason why it was indicated Page 7 of 9 ROMEOVILLE FIRE DEPARTMENT MANUAL Special ePCR Signature Situations The Pediatric Patient For pediatric incidents and only if the parent is unavailable, the caregiver at the scene may provide the signature (it may be a school official) or in the transport setting, the receiving facility RN may provide the signature The Patient under Arrest For incidents where a patient is under arrest and the patient is mentally competent, the patient may not only sign the pcr, but may consent or refuse treatment and sign the refusal. Note: if the patient is under arrest and the police officer wants the patient treated and transported against the patient’s will, the officer’s determination shall be followed. o Per the Romeoville Police policy on prisoner transports, when a patient is under arrest, the police officer is required to follow the ambulance to the hospital regardless of whether the patient is handcuffed. If the situation causes the charge medic to require the assistance of the police officer, the driver of the ambulance shall stop the ambulance while informing RFD dispatch to request assistance from the police officer. If a patient is exhibiting violent tendencies prior to transport or is not cooperative with the public safety personnel, the officer shall be present in the patient-care area of the ambulance during the transport. If a patient is unable to sign due to lack of competency or if handcuffed, and the patient is transported, the RN may sign the pcr. Finally, in situation where the patient refuses to sign the pcr, and won’t be transported, the police officer may only witness the word “Refused” documented on the pcr. Therefore, write the word “Witnessed by” under the signature line and have the officer sign underneath the entry. Page 8 of 9 ROMEOVILLE FIRE DEPARTMENT MANUAL Special Consent Situations Step Parent Consent for Treatment and Transport o The Step-Parent may authorize consent for treatment and transport of a minor only if the step-parent is a legal guardian of the minor, has adopted the minor or authorized in some type of written document to obtain medical care for the minor in the absence of the parent of the legal guardian Minor Consent for Treatment and Transport o A minor may consent for and refuse treatment and transport if  14-17 years of age (EHEMSS Refusal Policy)  If they are a parent  If they are married  If they are pregnant  If they have been legally emancipated through appropriate court proceedings (patient also has documentation)  Minors 12 and up seeking STD treatment or alcohol/drug addiction treatment Page 9 of 9