Documentation Flashcards
Six functions of a patient care report
Continuity of care Legal documentation Education Administrative Research Evaluation and quality improvement (QA/QI)
When to document a call
Every patient contact: transports, refusals, BLS to ALS, ALS to BLS Every scene arrival (non-transports): party denies need (PDN), unable to locate (UTL)
Cancelled while en route
ALS arrives prior (or simultaneous) to BLS and ALS transports
What should not be used for documentation?
PAR and OTHER
PCR includes:
Demographics:SSN, medical record number, insurance if applicable Chief complaint HPI:scene, subjective, OPQRST PMH: Meds, allergies PE Pertinent negatives Treatment and transport Narrative
Primary impression on the safety pad is versus the complaint
EMT’s impression
Patient’s complaint (can put in quotes if necessary)
Importance of narrative
Opportunity to give context, chronology and content
Special situations
EDP’s requiring restraint, weapons/threats, patient “quotes”, cardiac arrests, likely court cases, non-transports
When can someone refuse on behalf of another person?
Parent or guardian
Capacity to refuse:
Oriented, understand nature of illness and consequenes of refusal, ability to communicate, adult
Must be initiated soley by patient
Assessment/documentation must support decision
Party denies need
BEMS has arrived on scene and made contact with the party for which the ambulence was called
Individual presents with no signs or symptoms of illness or injury
Minimal or absent mechanism of injury and HPI
The party appears competent
Narrative supports decision
Additional documentation
Child abse, elder abuse, abuse of the disabled
