"Standard Operating Procedure for Patient Care Documentation PDF"

500.10 Patient Care Documentation Page 1 of 5 Standard Operating Procedure for Patient Care Documentation No: Reviewed date: Effective date: Supersedes: I. II. III. FR500.10 7/28/19 10/29/15 3/8/12 Type: Emergency Medical Service- 500 series Department: Las Vegas Fire & Rescue Signature: Expires: 7/...

500.10 Patient Care Documentation Page 1 of 5 Standard Operating Procedure for Patient Care Documentation No: Reviewed date: Effective date: Supersedes: I. II. III. FR500.10 7/28/19 10/29/15 3/8/12 Type: Emergency Medical Service- 500 series Department: Las Vegas Fire & Rescue Signature: Expires: 7/28/2024 INTRODUCTION A. Purpose: To establish a Las Vegas Fire & Rescue (LVFR) policy regarding the documentation of patient assessment and/or care rendered by LVFR personnel. B. Scope: This information is provided to all LVFR Suppression personnel. C. Author: The Deputy Chief of Emergency Medical Services (EMS), or designee, shall be responsible for the content, revision, and review of this information. RESPONSIBILITY A. It shall be the responsibility of all LVFR personnel to be familiar with patient care documentation requirements. B. The Company Officer is responsible for ensuring his/her subordinates follow the policy and complete all required Patient Care Records. DEFINITIONS A. Patient Care Report (PCR): a form used for documentation of patient assessment and/or care by medical providers. The PCR serves as a medical record, a legal document, and an essential record of research. B. Patient: As defined in the Emergency Medical Care Protocols (EMCP), any individual who, upon contact with an EMS system, has any of the following: 1. A complaint or mechanism suggestive of potential illness or injury; 2. Obvious evidence of illness or injury; or, 3. An individual or informed 2nd/3rd party caller requesting evaluation for potential illness or injury. 500.10 Patient Care Documentation 4. IV. Page 2 of 5 ***Note: These criteria are intended to be considered in the widest sense. If there are any questions or doubts, the individual should be considered a patient. C. Clark County EMS System, Emergency Medical Care Protocols (EMCP): a manual of the Clark County EMS System to provide guidance and standardization of prehospital patient care in Clark County. It is the responsibility of all LVFR personnel to be familiar with and follow the documentation requirements and instructions within the patient care documentation manual (PCDM). D. Las Vegas Fire & Rescue: Patient Care Documentation Manual (PCDM): a manual for LVFR personnel to guide them in their documentation of patient care. It is the responsibility of all LVFR personnel to be familiar with and follow the documentation requirements and instructions within the PCDM. E. Las Vegas Fire & Rescue: EMS Task Standards: a series of references for LVFR personnel to provide clear and succinct care recommendations for specific patient groups, such as: AMA – Against Medical Advice, STEMI – ST Elevation Myocardial Infarction, Advanced Airway Management, etc. It is the responsibility of all LVFR personnel to be familiar with and follow the documentation requirements and instructions within the LVFR EMS Task Standards. F. The Medical Records Confidentiality Act of 1995: an act that ensures confidentiality of all medically related records that contain personally identifiable information. Protected Health Information (PHI) is defined as “any information, including demographic information from an individual, whether oral or recorded in any form or medium.” SUBMISSION OF REPORTS A. All PCRs shall be entered into the designated electronic PCR software. B. A PCR will be completed for every patient and EMS call. C. When the LVFR unit does not transport the patient to a receiving facility, the associated PCR shall be completed within four (4) hours of the time at which the unit status changed to In Quarters. D. When the LVFR unit transports the patient to a receiving facility, the associated PCR for the patient shall be completed and the report shall be exported prior to the unit leaving the receiving facility. 500.10 Patient Care Documentation V. Page 3 of 5 DOCUMENTATION 1. Essential elements: All personnel will ensure that documentation is complete and accurate. Completion of appropriate checkboxes, flowcharts, flex fields, and a descriptive narrative will be the methods used to document all patient encounters. In addition to the information required to be in the PCR per the EMCP, the following must be included in the PCR: Incident number. 2. Unit Number. 3. Run Dispositions: Select the appropriate Run Disposition as indicated in the PCDM. 4. Patient date of birth. 5. Patient phone number. 6. Patient insurance information: medical and/or automobile as applicable. 7. Signatures: The following signatures must be obtained for all PCRs in which the patient was transported by LVFR: a) EMS Technician. b) Representative from Receiving Facility; either the Registered Nurse (RN) or Medical Doctor (MD) receiving the patient. c) Patient, Guardian, or Authorized Representative (1) 8. If unable to obtain the patient, guardian, or authorized representative signature, there are additional documentation requirements. Refer to the PCDM: Unable to Sign. File attachments: The associated Monitor file must be uploaded and attached to the PCR if the Monitor was used for any of the following purposes: a) Assessing and/or monitoring the cardiac rhythm; b) Obtaining a 12-lead electrocardiogram (ECG); c) Providing electrical therapy; cardioversion, defibrillation, and/or pacing, and/or 500.10 Patient Care Documentation d) Monitoring End-Tidal Carbon Dioxide (ETCO2) levels and/or waveform of an intubated patient. e) If the file upload and attachment process does not work properly, the following steps must be completed: (1) Print the code summary report, mark the report with the incident number, and send the report to the EMS Quality Improvement Coordinator for filing and storing. (2) Notify City of Las Vegas Information Technologies (IT) of the file upload and attachment failure, log an IT ticket, and document the failure, notification, and IT ticket number in the PCR narrative. 9. Select the appropriate Provider Impression(s). 10. Select the appropriate and applicable EMCP under which the patient was treated. 11. At least two (2) full sets of vital signs for patients treated under the following Run Dispositions: 12. B. Page 4 of 5 a) Treated/Transported; b) Treated/No Transport; c) Transported/Refused Care; and d) No Transport/Refused Care. Patient care transfer: a) Time of care transfer, and b) To whom care was transferred Patient Refusals: The following documentation is required for all incidents in which a patient refuses treatment and/or transportation against medical advice (AMA) and shall reflect the amount of time and effort the EMS provider underwent to encourage the patient to accept care. 1. The patient had decision making capacity. 500.10 Patient Care Documentation VI. Page 5 of 5 2. A complete patient assessment and two (2) complete sets of vital signs. 3. A description of the patient and pertinent aspects of the incident to include the reason(s) why the patient refused care and the steps taken to accommodate their concerns. 4. Family, friends, and/or medical control were encouraged to convince the patient to consent to treatment and/or transport. 5. The recommendation of treatment and/or transport was recommended to the patient. 6. The risks associated with refusing care were explained to the patient, and the patient understood the risks. 7. The patient was told their wishes were being respected, and to call 9-1-1 if the condition(s) worsened or the patient changed their mind. 8. The LVFR waiver form or the PCR signed by the patient indicating the refusal of care. DOCUMENT DESTRUCTION A. All personnel shall follow the City of Las Vegas Policy #ROP CL-201 Destruction of Public Records (Available electronically from the Office of the City Clerk Policies and Procedures intranet). B. All documents and written materials that contain protected health information and are not intended to be part of the medical record shall be destroyed by shredding or by placing the documents into a Department approved, locked disposal container if available. C. Documents and written material that are intended to be part of the medical record should be sent to Administrative records personnel by intradepartmental mail.