Bernalillo County Fire & Rescue EMS Report Writing Manual PDF

**Bernalillo County Fire & Rescue** **EMS Report Writing Manual** **June 22, 2023** **Version 3.0** **Purpose** This document is intended to provide the information necessary to properly report emergency medical responses made by Bernalillo County Fire and Rescue (BCFR). The department has est...

**Bernalillo County Fire & Rescue** **EMS Report Writing Manual** **June 22, 2023** **Version 3.0** **Purpose** This document is intended to provide the information necessary to properly report emergency medical responses made by Bernalillo County Fire and Rescue (BCFR). The department has established this document to meet the requirements of federal state and local government agencies. This document shall serve as a regulation for the reporting of the patient information and completing documentation for EMS calls. Do as much as you can in the best interest of the patient and document everything. Nothing can take the place of a detailed and well-documented report. That is always your best defense. I. **Definitions** A. **Records Management System (RMS) --** The record management system herein is the web-based service contracted by the department. B. **EMS Reports --** Are defined as those documents that are to be generated after units have responded to an EMS call in which they were dispatched to, and an incident number has been created by the communications center. C. **Primary Care Provider --** The EMS provider with the highest level of licensure or the provider who performed the greatest amount of assessment or patient care during the incident. D. **Electronic Signatures --** As the login and password is user defined and should be only known as to the user. II. **Roles** E. All Personnel 1. All reports shall be generated using the currently accepted RMS. 2. Battalion Commander (BC) a. BC will have supervisory authority in the records management system and are: 1. Authorized to delete any reports in the RMS that meet the following criteria, erroneous, turned over to (TOT), duplicate or test call. 2. Not authorized to delete any other report type from the RMS without first coordinating through the EMS division or given approval by the Fire Chief. 3. The BC may associate or reassign report responsibilities to the company officers as deemed necessary except for those incidents during which the BC acted as incident commander for most of the incident. The BC will be responsible for such reports in coordination with the care providers and company officers. 3. Company Officer (CO) b. Supervisor Authority 4. The captains will have supervisory authority in the records management system and are authorized to delete any reports in the RMS that meet the following criteria erroneous, turned over to (TOT), duplicate or test call. 5. The CO has the authority to assign reports to whomever they deem is responsible for the report. 6. In an effort to spread the workload and maintain members report-writing skills the CO may assign reports to members of the crew with the consideration given to type of call, severity of call, procedures performed with the exception that the primary care provider is completing the necessary elements based on their care. 7. The CO/Paramedic is responsible for reviewing all reports created in the RMS by the personnel under their command. 8. Once the CO/Paramedic has reviewed the report they will lock the report to indicate that it is complete. a. No EMS incident reports from their station are to be left in the unlocked status at the end of shift. 9. In the event there is a report that has not been completed prior to the CO getting off shift they are to brief the oncoming CO that there is someone staying to finish the report and they will have to review the report once it is completed. 10. EKG Strips -- In the event that you receive paper ECG strips from another agency, take a photo utilizing the MDT tablet and upload it into your report in the RMS or download the ECG from the agency you responded with. Shred the original ECG strips after you verify the photo has uploaded. III. **Timeline For Report Submission** **New Mexico state statute requires:** ***"All certified EMS agencies except special event EMS shall complete in a timely manner and keep on file a clearly written or computer-generated patient care report for each patient who is provided with emergency medical care or transported. Each patient care report shall be authored by the provider(s) actually responsible for the patient care, and shall be completed within forty-eight hours of the provision of care to the patient." 7.27.10.12.A NMAC*** F. BCFR requires the primary care provider to complete the EMS report as soon as practical/possible during the shift/cycle for report accuracy. G. All reports will be completed before the end of the provider's shift, no exceptions. H. All reports must be completed in a timely manner so that they can be reviewed by the company officer before the end of the cycle. I. Any report in which controlled drugs were administered or wasted must be completed immediately. Controlled substances will not be restocked until the report is complete. IV. **Report Contents** J. In the current department RMS, the first section, the fire report portion is the overall report for the event. 4. A report shall be generated even if the responding unit is cancelled at any time after an incident number has been generated. K. Minimum report criteria: The patient report shall include, but not be limited to: 5. Incident response information, dispatch address, date, alarm number, MPDS code, times as recorded by communications, and crew names and codes. L. Narrative the model of narrative format CHARTDE (chief complaint, history, assessment, treatment, transport, dispositions, exceptions) is the only acceptable format. The information needs to be as accurate and complete as possible however it must contain the following: 6. Dispatch 7. Chief Complaint 8. Current History 9. Physical Exam 10. Past Medical History as it pertains to current medical complaint. 11. Medical communications with receiving facility or agency. 12. Treatment and response to treatment 13. Outcome/Disposition 14. End the narrative with the author's crew code. M. The narrative section in the RMS as well as any applicable supporting documentation shall be limited to the facts and not include superfluous, self-promoting, inappropriate or editorial comments. 15. This includes any non-appropriate photos, subject matter attachments or false information that is inappropriate or unrelated to the call. 16. RMS reports and the supporting documents are subject to subpoena and are therefore considered legal documents for the fire department. 17. Any deviation from report writing criteria can and will be subject to disciplinary action up to and including termination. 18. Any report in which controlled drugs were administered or wasted will be documented in the patient narrative as well as in the narcotic use waste signature sheet in the RMS. 19. Vital signs and other physical exam findings should include: c. Pulse rate and quality d. Respiratory rate and effort e. Blood pressure f. Oxygen saturation g. Level of consciousness h. Skin condition i. Glucometry j. Pupillary response k. Lung sounds 20. Procedures: All procedures are to be documented in the procedure field of the report and should be documented in the narrative as well. l. The employee who performed the procedure shall be listed. m. If a non-employee performs a procedure while BCFR personnel are involved in patient care, this procedure should be noted in both the procedures and the patient narrative for accountability purposes and the personnel or person shall be identified. n. All cardiac and syncope related calls will include performing and documentation of the 12 lead EKG. This will include documentation of why the procedure was not performed. o. Any controlled substance administration where the entire package amount is not used will be wasted and witnessed by appropriate EMS personnel. This procedure will be documented in the narcotic use/waste signature sheet and in the narrative section of the report. p. All cardiac related calls must include patient documentation of ASA administration. This will include documentation of why the medication was not administered. q. Following the administration of a medication a follow-up set of pertinent vital signs must be documented. r. Signatures: Completed EMS report shall be marked as reviewed and locked by the company officer and or paramedics and locked at the time of completion. s. Multiple patient incidents: 11. If there are multiple patient records created by multiple authors, each author shall set to the status of completed his or her own patient records. 12. The main report author shall set the associated fire incident to complete. 13. The incident commander or company officer in charge of the event shall authorize the end of the incident report which may contain one or more patient records. t. Non-Patient Refusals: All non-patient refusals must have a refusal signature sheet in the RMS with an electronic signature, or a current refusal document completed and submitted to the EMS division. All information obtained from the patient shall be input into the RMS under an electronic patient care report (EPCR) this will ensure that an non-patient is searchable in the system and available should a records request be made. u. Patient Refusals: All BCFR patient refusals shall have one documented set of vitals, or two documented sets of vitals if not within normal limits and the reason for refusal. If a patient refuses vital signs, document his or her refusal and your discussion of the risks and benefits in the chart. 14. If the patient declines, you need to follow protocol and document criteria for the refusal. b. Document your discussion with the patient regarding the risks of refusing. c. Document the patient\'s ability to understand this discussion. d. Attempt to get the patient to sign the refusal under the appropriate refusal section. e. If the patient is in custody of law enforcement and wishes to be transported to the hospital and law enforcement does not want the patient to go by ambulance or at all, the officer will need to be made aware that they are taking on full responsibility of the patient and your documentation should include the officer's name and badge number. Document your discussion with the patient and the officer regarding the risks of refusing. 15. Note: Signatures from patients, guardians, law enforcement, witnesses, etc., are all helpful. They are not imperative, and certainly not worth creating conflict with an officer on scene. A well written narrative containing your offer to transport, a description of the risks of refusing, and as much additional detail as possible will be sufficient to provide reasonable protection for you should the case go to court it will be very easy to determine which officer was on scene. V. **BCFR Unit Transports to the Hospital** N. A pre-hospital EMS Patient Care Record must be provided for the hospital by the transporting agency. ***"Completed patient care records: An EMS agency that transports a patient shall, upon delivery of the patient to the hospital, deliver a copy of the completed pre-hospital patient care record to the receiving facility's emergency department for inclusion in the patient's permanent medical record. In the event that the transporting unit is dispatched on another call before the pre-hospital patient care record shall be delivered to the receiving hospital's emergency department no later than forty-eight hours after the transportation and treatment of the patient." 7.27.10 NMAC*** O. When completing the RMS report please ensure that the patient disposition is set to treated and transported by BCFR. This box is only checked yes if BCFR transports a patient. P. If BCFR does not transport the patient and another agency does, please select the "treated and transported by" box and choose the appropriate agency. Q. If BCFR personnel ride in with AAS they will provide documentation describing any treatment or actions they performed while riding into the hospital. The documentation should also include any changes in the patient\'s condition that occurred during transport. This documentation should be placed into the patient transport section of the patient narrative as supplemental information to show continued care for accountability purposes. 21. Remember to fill out the appropriate box referring to how many personnel rode in with the AAS unit. VI. **Contingency for records management system failure:** R. Should the RMS become unavailable due to electronic failure notify the company officer. The company officer will then notify the Battalion Commander and the Battalion Commander shall notify the Division Chief of EMS. 22. The Report must be entered into the RMS system once it becomes available. VII. **Public requests for EMS reports:** S. Any request to view or obtain copies of EMS reports must be made directly to the EMS division. VIII. **Billing Requirement** T. Patient or patient representatives signature authorizing billing and acknowledging HIPAA requires a signature from either. U. EMT's signature when patient or representative is unable to sign HIPAA and billing authorization. Must provide a reason. V. EMT's signature verifying transport was medically necessary. If you are not sure, select N/A. EMT/Paramedic must sign. W. Signature person that patient was turned over to at the hospital. Type the person's name below. X. EMS provider signature to verify care provided and report accuracy. EMT/Paramedic must sign. **Attachment A:** **Reference for PCR** Dispatch: Units dispatched, response code, reported complaint by dispatch. Chief Complaint: Age, sex, weight, C/C. HPI: Description of complaint (How long has this been going on for, has this happened before.) OPQRST when applicable. Pertinent negatives and positives. Any other information from people on scene. **Assessment** **Medical assessment:** How the patient was found. LOC/AVPU. Airway: Open, self-maintained, stridor, secretions, trauma, swelling. Breathing: Normal, rapid, shallow, work of breathing, breath sounds. Circulation: Pallor, cyanosis, diaphoretic, pink, warm, dry, hives, hemorrhage. Pulses: Regular/irregular/strong/weak/rapid/slow. H.E.E.N.T: Head: Angio edema, hives, facial droop, slurred speech. Ears: Discharge of fluids. Eyes: Reactiveness, equal, size, discharge, growths. Nose: Mucous. Throat: JVD, tracheal deviation. Neck/back: Step-off or deformities, bruising. Chest: Any abnormal findings. ABD: Distention, rigidity, rebound tenderness, bruising, quadrant affected. Pelvis: Any abnormal findings. Limbs: CMS, weakness, numbness, tingling, edema, discoloration, ambulatory. **Trauma assessment:** How the patient was found, LOC/AVPU. Airway: Open, self-maintained, trauma, swelling, burns. Breathing: Normal, rapid, shallow, work of breathing, breath sounds. Circulation: Pallor, cyanosis, diaphoretic, pink, warm, dry, hives. Pulses: Regular/irregular/strong/weak/rapid/slow. Description of hemorrhage: Arterial/venous/active/dried blood. H.E.E.N.T.: Head: Trauma and location. Ears: Discharge of fluids, trauma. Eyes: Trauma, hemorrhage, discharge, reactiveness, equal, size. Nose: Trauma, hemorrhage. Throat: JVD, tracheal deviation, trauma. Neck/back: Step-offs, deformities, trauma. **RX:** Primary, secondary, vitals, procedures performed. If EKG performed, paramedics interpretation of EKG. How patient was moved to gurney, any issues with loading the patient into the transport unit. **Transport:** Unit, code 1, code 3. If fire department personnel rides in or transports: Vitals, procedures, any changes in patient condition, trauma alert, STEMI alert, stroke alert, sepsis alert. **Destination:** Hospital patient was taken to. The provider and room patient was transferred to. **Exceptions:** Anything that prevents or interferes with patient care. Delays in treatment and or transport. **Attachment B:** **Approved Medical Abbreviations** A&O x3 alert and oriented to person, place, and time A&O x4 alert and oriented to person, place, time, and event A-FIB atrial fibrillation AMA against medical advice AC antecubital AED automatic external defibrillator AIDS acquired immune deficiency syndrome APGAR infant assessment scale ASA aspirin BBB bundle branch block BGL blood glucose BP blood pressure BVM bag valve mask CABG coronary artery bypass graft CAD coronary artery disease C-SECTION cesarean section C-SPINE cervical spine C/O complaint of CC chief complaint CHF congestive heart failure CNS central nervous system CO2 carbon dioxide COPD chronic obstructive pulmonary disease CP chest pain CPR cardiopulmonary resuscitation CSF cerebral spinal fluid CT computed tomography scan CVA cerebrovascular accident (stroke) D5W 5% dextrose in water D/C discontinue DKA diabetic ketoacidosis DNR do not resuscitate DOA dead on arrival DVT deep vein thrombosis ECG electrocardiogram EJ external jugular EMS emergency medical services EMT emergency medical technician ETA estimated time of arrival ET endotracheal ETOH ethanol (alcohol) ETT endotracheal tube g grams GCS Glasgow coma scale GI gastrointestinal GSW gunshot wound gtts drops HEENT head, eyes, ears, nose, throat HIV human immune deficiency virus HR heart rate HTN hypertension HYPER above or high HYPO below or low ICU intensive care unit ICP intracranial pressure IM intermuscular IO intraosseous IV intravenous IVP intravenous push JVD jugular vein distension Kg kilogram L&D labor and delivery LBB left bundle branch block lb. pound LLQ left lower quadrant LOC level of consciousness L-SPINE lumbar spine LUQ left upper quadrant mcg microgram MCI mass casualty incident mEq milliequivalents mg milligram MI myocardial infarction (heart attack) MICU medical intensive care unit MRI magnetic resonance imaging MS/MSO4 morphine MVA/MVC motor vehicle crash N/V/D nausea/vomiting/diarrhea NC nasal canula NKDA no known drug allergies NRB non-rebreather NS normal saline NSR normal sinus rhythm O2 oxygen OPA oropharyngeal airway OB/GYN obstetrics/gynecology OTC over the counter PAC premature atrial contraction PCN penicillin PE pulmonary embolus PEA pulseless electrical activity PEEP positive end expiratory pressure PEARL pupils equal and reactive to light PJC premature junctional contraction PMHx past medical history PO orally POV privately owned vehicle PRN as needed PSVT paroxysmal supraventricular tachycardia PT patient PVC premature ventricular contraction RLQ right lower quadrant ROM range of motion RUQ right upper quadrant Rx treatment SIDS sudden infant death syndrome SOB shortness of breath SPO2 oxygen saturation by pulse oximeter STD sexually transmitted disease SQ subcutaneous SVT supraventricular tachycardia T-SPINE thoracic spine TCP transcutaneous pacing TIA transient ischemic attack TKO to keep open UTI urinary tract infection V-FIB ventricular fibrillation VS vital signs V-TAC ventricular tachycardia YO years old WPW Parkinsons-white syndrome 1\* primary 2\* secondary \~ approximately