Documentation PDF

Dr. Tarek Esmael LECTURER OF GENERAL & LAPAROSCOPIC SURGERY (M.D) GENERAL SURGERY 1 I.Documentation A.Reasons for documentation 1. Medical uses 2.Administrative uses 3.Legal uses 4.Educational and rese...

Dr. Tarek Esmael LECTURER OF GENERAL & LAPAROSCOPIC SURGERY (M.D) GENERAL SURGERY 1 I.Documentation A.Reasons for documentation 1. Medical uses 2.Administrative uses 3.Legal uses 4.Educational and research uses 5. Evaluation & Quality improvement B. Prehospital care report (PCR) 1.Functions a.Continuity of care - a form that is not read immediately in the emergency department may be referred to later for important information. 2 b.Legal document (1) A good report has documented what emergency medical care was provided, the status of the patient on arrival at the scene, and any changes upon arrival at the receiving facility. (2) The person who completed the form ordinarily must go to court with the form. (3) Information should include objective and subjective information and be clear. C. Educational-used to demonstrate proper documentation and how to handle unusual or uncommon cases d.Administrative (1) Billing (2) Service statistics e.Research f.Evaluation and continuous quality improvement 3 2. Use a.PCR formats (1) Traditional written form with check boxes and a section for narrative (2) Computerized version where information is filled in by means of an electronic clipboard or a similar device b.Sections (1) Administrative information Run data-date, times, service, unit, names of crew (2) Demographic data Patient data-patient name, address, date of birth, insurance information, sex, age, nature of call, mechanism of injury, location of patient, treatment administered prior to arrival of EMT- Basic, signs and symptoms, care administered, 4 baseline vital signs, SAMPLE history, and (3) Check boxes ( Vital signs ) (a) Be sure to fill in the box completely. (b) Avoid stray marks. (4) Narrative section (if applicable) (a)Describe, don't conclude. (b)Include pertinent negatives. (c)Record important observations about the scene (e.g., suicide note, weapon). (d)Avoid radio codes. (e)Use abbreviations only if they are standard. 5  (f)When information of a sensitive nature is documented, note the source of that information (e.g., communicable diseases). (g)State reporting requirements. (h)Be sure to spell words correctly, especially medical words. If you do not know how to spell a word, find out or use another word. (i)For every reassessment, record time and findings. (5) Other state or local requirements e.g. Treatment provided to the patient & response. 6  C. Minimum data set 1.Patient information gathered at time of EMT-Basic's initial contact with patient on arrival at scene, following all interventions, and on arrival at facility. a.Chief complaint b.Level of consciousness (AVPU)-mental status c.Systolic blood pressure for patients older than 3 years d.Skin perfusion (capillary refill) for patients younger than 3 years e.Skin color and temperature f.Pulse rate g.Respiratory rate and effort 7 2.Administrative information a.Time incident reported b.Time unit notified c.Time of arrival at patient d.Time unit left scene e.Time of arrival at destination f. Time of transfer of care 3.Accurate and synchronous clocks D.Legal concerns 1. Confidentiality - the PCR form itself and the information on the form are considered confidential. Be familiar with state laws. 2. Distribution - local and state protocol and procedures will determine where the different copies of the form should be distributed. 3. Documentation of refusal of treatement a. Competent adult patients have the right to refuse treatment. 8 b.Before the EMT-Basic leaves the scene, however, he or she should: (1)Try again to persuade the patient to go to a hospital. (2)Ensure the patient is able to make a rational, informed decision (e.g., not under the influence of alcohol or other drugs, or illness/injury effects). (3)Inform the patient why he should go and what may happen to him if he does not. (4)Consult medical direction as directed by local protocol. (5)If the patient still refuses, document any assessment findings and emergency medical care given, then have the patient sign a refusal form. (6) Have a family member, police officer, or bystander sign the form as a witness. If the patient refuses to sign the refusal form, have a family member, police officer, or bystander sign the form verifying that the patient refused to sign. 9 7. Complete the prehospital care report. (a)Complete patient assessment. (b)Care EMT-Basic wished to provide for the patient (c)Statement that the EMT-Basic explained to the patient the possible consequences of failure to accept care, including potential death (d)Offer alternative methods of gaining care. (e)State willingness to return. 10 4. Falsification issues a.When an error of omission or commission occurs, the EMT-Basic should not try to cover it up. Instead, document what did or did not happen and what steps were taken (if any) to correct the situation. b.Falsification of information on the prehospital care report may lead not only to suspension or revocation of the EMT-Basic's certification/license, but also to poor patient care because other health care providers have a false impression of which assessment findings were discovered or what treatment was given. c. Specific areas of difficulty (1)Vital signs-document only the vital signs that were actually taken. (2)Treatment-if a treatment such as oxygen was overlooked, do not chart that the patient was given oxygen. 11 d.Correction of errors (1)Errors discovered while the report form is being written (a)Draw a single horizontal line through the error, initial it, and write the correct information beside it. (b)Do not try to obliterate the error-this may be interpreted as an attempt to cover up a mistake. (2)Errors discovered after the report form is submitted (a)Preferably in a different color ink, draw a single line through the error, initial and date it, and add a note with the correct information. (b)If information was omitted, add a note with the correct information, the date, and the EMT-Basic's initials. 12 E.Special situations/reports/incident reporting 1.Multiple-casualty incidents (MCI) a.When there is not enough time to complete the form before the next call, the EMT-Basic will need to fill out the report later. b.The local MCI plan should have some means of recording important medical information temporarily (e.g., triage tag, that can be used later to complete the form). c.The standard for completing the form in an MCI is not the same as for a typical call. The local plan should have guidelines. 2. Transfer-of-care report. 13 3. Special situation reports a.Used to document events that should be reported to local authorities or to amplify and supplement primary report b.Should be submitted in timely manner c.Should be accurate and objective d.The EMT-Basic should keep a copy for his or her own records. e.The report, and copies if appropriate, should be submitted to the authority described by local protocol. f.Exposure g.Injury. Continuous quality improvement. gathered from the prehospital care report can be used to analyze various aspects of the EMS system..This information can then be used to improve different components of the system and prevent problems from reoccurring. 14. SOAP s >> subjective o >> objective A >> Assessment P >> Plan. CHART C --- chief complaint H --- History A --- Assessment R --- Rx T --- Transport. CHEATED C --- chief complaint T --- Treatment H --- History E --- Evaluation E --- Exam D --- Disposition 15 A --- Assessment