200.07 Patient Care Reporting.pdf

St. Johns Fire District Standard Operating Guideline Subject: Patient Care Reporting & Quality Review Number: 200.07 Effective: 10/20/2023 Approved By: Chief Ryan Kunitzer Revised:...

St. Johns Fire District Standard Operating Guideline Subject: Patient Care Reporting & Quality Review Number: 200.07 Effective: 10/20/2023 Approved By: Chief Ryan Kunitzer Revised: Page: 1 of 4 Purpose: The purpose of this policy is to establish the minimum requirements for patient care reporting and quality review by the St. John’s Fire District (STJFD). Objective: To have a standardized process for patient care reporting and quality assurance review. Policy: 200.07 Patient Care Reporting – General Electronic patient care reporting (ePCR) software is used to formally document all patient encounters and treatment. The ImageTrend “Field” software has been approved and adopted by medical control as the ePCR software for the STJFD. All required fields in the reporting software shall be accurately completed. All ePCRs shall be completed within twenty-four hours of the incident notification in compliance with the Department of Health and Environmental Control (DHEC) Standard 61-7. Any other fields that are considered pertinent to the medical incident should also be completed. Vital signs shall be documented for each patient encounter. Information reported becomes part of the patient’s medical record and it is imperative that the information provided is accurate. ePCR Narrative The narrative should serve as an opportunity for the emergency medical technician (EMT) or Paramedic to further explain and document treatment information on a patient. Narratives should include observations, interventions, assessment of the patient, and other pertinent information for the patient record. The chronological format shall be utilized as the standard format for all narratives. The format is as described below: Dispatched To: A brief description of the initial call for service to include units dispatched. Upon Arrival: Describe the incident scene.  St. Johns Fire District Standard Operating Guideline Patient Care Reporting & Quality Review Policy Number: 200.07 Chief Complaint: Document the patient’s expressed chief complaint and secondary complaint(s) if applicable Primary Assessment: You first impression, patient’s level of consciousness, airway, breathing, circulation, history of present illnesses, past medical history, and life- threatening conditions. Secondary / Focused Assessment: Information that pertains to a detailed physical exam, or a focused assessment, pertinent negatives, lung sounds, and blood glucose level. Treatments: All treatments that were provided to the patient. All vitals observed outside of established normal limits. Ongoing Assessment: The patient’s response to treatments, medications or additional assessments that were performed. Notes: The EMT or Paramedic should include a description of their patient turnover to the transporting EMS agency. This should include the ALS / BLS transport unit number or other identification. Detailed information relative to the transfer of patient care to the transporting agency should be included. Include any additional information that you feel needs to be documented. The narrative format provided accounts for the minimum requirements of narrative writing. Members should add any additional pertinent information that would bring clarity to any aspect of patient care, on-scene assessment, or the environment encountered. The following serve as additional required information in the narrative: Airway placement shall be confirmed by checking chest rise and lung sounds. Consideration for capnography should be documented if a device was used or present that is capable of this process. If a patient with injury refuses treatment, the EMT or Paramedic shall document findings as you would for any other patient adhering to the criteria above and the Charleston County Clinical Operating Guidelines. A medical treatment refusal form shall be completed for any patient who originally had a complaint of injury or illness. Notifications Notification shall be made to the STJFD Medical Battalion Chief anytime an automatic external defibrillator (AED) is used. This notification is to ensure that the data is downloaded from the AED for analysis and record-keeping. 2|Page  St. Johns Fire District Standard Operating Guideline Patient Care Reporting & Quality Review Policy Number: 200.07 Patient Refusals The STJFD responds to a variety of medical incidents ranging from low acuity to cardiac arrest. When STJFD personnel arrive at the scene of a medical incident where the patient chooses to refuse care or transport, the following shall occur. The EMT shall insure that the STJFD patient refusal form is completed and signed by the patient. The person completing the ePCR shall select the patient disposition of “refusal” within the ImageTrend NEMSIS 3.5 system. o The ePCR report writer shall document the patient’s orientation and education of refusal within the tab that opens following the selection of “refusal” within the report. The signed refusal form shall be uploaded into the ePCR in.pdf format. o Should the report writer be unable to scan and upload the refusal form into the ePCR, the following process shall be used. ▪ The original signed refusal form shall be placed in a sealed form envelope and addressed to the Chief Medical Officer; this form shall be delivered to headquarters within 48 hours of the incident. ▪ The Chief Medical Officer shall scan and upload the signed refusal form and attach it to the ePCR. Medical Quality Assurance and Improvement The purpose of the quality improvement program is to ensure that emergency medical care is rendered in a professional and systematic format. It shall be the responsibility of the Medical Battalion Chief, with coordinated efforts from the command staff, and Medical Director to provide a thorough review of emergency medical incidents. Company officers shall be responsible for ensuring patient care reports are completed by personnel assigned to them. This shall be accomplished by accessing the ePCR reporting software and ensuring that all ePCRs assigned to their personnel are complete and locked. It shall be the responsibility of the Medical Battalion Chief to initiate a Level 1 review on all incidents that mandate review. The following shall be the base activators for a Level 1 review: 1. Cardiac Arrest (working or DOA) 2. Insertion of any airway adjuncts 3. Citizen complaints 4. Medication Administration (oxygen administration is not included) 5. Patient Refusals obtained by STJFD EMTs 6. Other circumstances, as determined by the Fire Chief, Command Staff, Medical Battalion Chief, or Medical Director. 3|Page  St. Johns Fire District Standard Operating Guideline Patient Care Reporting & Quality Review Policy Number: 200.07 Formal Quality Improvement The STJFD will utilize a process involving three levels of review in its Quality Improvement Program. Level 1: This level of review will be performed on reports that warrant a review based on the identified priorities of the Fire Chief, Medical Battalion Chief, or Medical Director. Level 1 reviews will be assigned by the Medical Battalion Chief and completed by designated EMTs or Paramedics within 14 days of the assignment date. The focus of this review will be the care provider’s compliance STJFD Standard Operating Guideline 200.07 along with appropriate protocol selection and adherence to the selected protocol. Level 2: Reviews will elevate to Level 2 when the EMT or Paramedic conducting a Level 1 review identifies infractions or deviations from protocol exist beyond documentation or clerical errors. Upon these findings, the EMT or Paramedic will request a Level 2 review to be conducted by the Medical Battalion Chief. The Medical Battalion Chief will then advise the member of the outcome of the review if resolved at this level. If not resolved the review will be elevated to Level 3. Level 3: Reviews will elevate to Level 3 when further action is warranted based on the findings of the Level 2 review conducted by the Medical Battalion Chief. All supporting documentation will be forwarded with the request. Level 3 reviews will be conducted by members of Command Staff under the consultation of the Medical Director as deemed necessary. This level of review and any subsequent action will be conducted by Command Staff personnel. The designated Command Staff member(s) would then communicate the results and required action to the member being reviewed. 4|Page