Lecture 5 - Documentation PDF

📄 Lecture 5 - Documentation Documentation LEC Typical Paramedic Documents → Ambulance Call Report (ACR) → Incident Report → Occurrence Report → Exposure Report → Injury Report (ie. WSIB) → Pa...

📄 Lecture 5 - Documentation Documentation LEC Typical Paramedic Documents → Ambulance Call Report (ACR) → Incident Report → Occurrence Report → Exposure Report → Injury Report (ie. WSIB) → Paramedic Referrals (CREMS) → Personal Notes → Collision/ Accident Report → Equipment Malfunction Report → Daily Documentation Importance of Documentation → May be only source of info → Provides source for Clinical data → Billing & Administration → Data collection/ Research → Legal record of incident → Medical audits by BH → Quality improvement ❊ Not Documented = Not Done Lecture 5 - Documentation 1  General Documentation Guidelines → Kept for 10 years or more → Must be suitable for use as evidence or legal proceedings (Be mindful of what you say, how you say it) → Subject to confidentiality policies listed in the Ambulance & PHIPA → All reports must be completed by end of shift → ACR whenever a request for an ambulance is initiated (Dispatch tells us what to fill out or everything you do to pt you fill out in ACR) ▫︎ If you participated or were part of an event, you too must sign the report ▫︎ Cancelled calls still get an ACR → Use medical terms & correct spelling ▫︎ Use commonly accepted abbreviations ▫︎Common Acronyms → Ensure times are recorded & Accurate → Include special circumstances in remarks → Pertinent(relevant) findings (expected things you would find given chief complaint i.e. chest complaint, find shortness of breath) → Pertinent negatives (things that are not there with chief complaint i.e. chest complaint but no shortness of breath) → Pertinent oral statements ▫︎Made by patients or other on-scene personnel → Accurate → Unaltered ( don’t leave gaps where info might get altered) → Legible → Timely Lecture 5 - Documentation 2  → Free from non-professional/ extraneous Information → Consider your audience Consequences of Errors → Implications to medical care → Legal implications → Statistical errors ACR Guidlines → Report essential data → Protect confidentiality → Ensure security of pt information records & documents → Collect current & historical pt information → Document in an objective & non-judgmental manner → Ensure appropriate distribution → Students CANNOT complete ACR Incident Report (describing what happened without pt details) → Complete an incident report when: ⇢ Complaint regarding service ⇢ Any investigation is required ⇢ There is an unusual Occurrence: ▫︎Unusual response or service delays ▫︎Delay in accessing pt ▫︎Suspicious or unexpected death ▫︎Suspected or actual criminal scenes Lecture 5 - Documentation 3  ▫︎Equipment failures affecting pt care, outcome or response ▫︎Any harm or risk of harm to pt, crew, or any other person in care of or transported by ambulance crew → Objective observations, conversations, surroundings → Chronological order → Sentence or point form → Mistakes → Admissible in any legal proceeding, can also be requested by MOH Vehicle Accident/ Collision → For ambulance service records → Used for insurance purposes → Documents facts only, nothing subjective → Collect necessary information: ▫︎ Other driver’s info, number of injured & injury ▫︎Get pictures if possible ▫︎Get names & Phone numbers of witnesses Personal Notes → Excellent habits easy if started from the beginning → Admissible in court & can be subpoenaed → Beginning of shift entry: ▫︎Date, shift time ▫︎Partner, vehicle #, Station ▫︎Weather conditions ▫︎Run # & Times ▫︎Other vehicles, call details - No pt details Lecture 5 - Documentation 4  Vehicle/ Station Checklist → Assist with performing thorough check of patient care equipment → Assists with checking working of your ambulance → Written report of equipment to next crew → Easier to track down missing equipment → Helps with supply inventory and ordering → Track damages to vehicle/ equipment Controlled Substances → Found on ALS vehicles → Check at Start & end of shift counts → Prescription record (usage) → Breakage → Witness usually required Ambulance Call Report Documentation General ACR Guidelines → Fields “right justified” → Black ballpoint pen (no fancy colors) → Legible (readable) → Accurate, objective → Use only accepted abbreviations/ acronyms → Medical terminology → Block letters preferred Lecture 5 - Documentation 5  → CNO = COULD NOT OBTAIN → DNO = DID NOT OBTAIN → No blank fields → Single bar through errors & initial (mistakes = put a line so it could be seen & correct under) Demographics - Pick up Codes A: Airport/ Heliport M: Mining Site/ Quarry B: Apartment/ Condo. Buildings N: Long-Term Care Home C: Construction Site O: Office Building D: Medical Office/ Clinic P: Sports Facility/ Arena E: Nursing Outpost Q: Farm F: Factory/Industrial Site/ Railway/ Dockyard R: House/ Town House G: Hotel S: Street/ Highway/ Road H: Hospital (Acute or Non-Acute) T: Fairground/ Park I: Indoor shopping mall U: Retirement Home J: Jail/ Prison V: Golf Course K: Single Store/ Stripe Mall W: Water/ Boat L: School/ College/ University Y: Casino Z: Other (Describe in Remarks) Clinical - Trauma Code = In the ACR paper you have Goes in the Relevant Past History, Medications, Allergies, Treatment Prior to Arrival, Cardiac Arrest Information, General Appearance, Head/Neck, Chest, Abdomen, Back/Pelvis, Extremities - in the ACR ACR - Skin Conditions Reference = In the ACR paper you have ACR - Procedures/Treatment = In the ACR paper you have Lecture 5 - Documentation 6  Goes in the Clinical Treatment/ Procedures LEARN ALL THE CODES IN THE ACR PAPER/ or THE TOPICS CODES Lecture 5 - Documentation 7