Vol.1-Ch.10 "Documentation" Flashcards
What is the/a prehospital care report (PCR)? What does it document? (3)
A factual record of events that occur during an EMS call or other Pt contact.
It documents:
- what you did
- when you did it
- the effects of your interventions
3 major goals of the PCR (pt care report)?
- Provide info to subsequent health care professionals about the Pt and treatments provided in the prehospital setting
- Provide essential information for proper billing of the Pt
- Provide a legal record of the call’s circumstances
Who benefits from you documentation and why?
- Medical staff at hand off : because it can set a baseline for comparing assessment and trends of improvement or deterioration for the Pt
- Administration : it can help determine the effectiveness or quality of response time vs call location, use of lights/sirens, date/time, or the individual paramedics vs the ems system
- Research : to aid research teams in studying drugs, interventions, medical devices, etc
- Legal/Lawyers : your PCR is a part of your Pts permanent medical record and can be used in legal court proceedings
Should you write Pt info on your gloves that you need for your PCR?
NO!
What is a bubble sheet?
A type of PCR where your info is entered by filling in “bubbles” like a scantron and can be scanned into a computer as well
Is it acceptable to use plain English and medical terminology in a PCR?
Yes, medical terminology is better but when you do not know correct spelling it is acceptable to use plain English as a back up (better to put “chest” instead of misspelling thorax”
Abbreviations VS Acronyms
Both use initial letters to form; however an acronym is an abbreviation you can pronounce as a word (such as AIDS = acronym. but CPR = Cardiopulmonary Resuscitation = abbreviation)
Using abbreviations and acronyms can be confusing as the same ones can be usesd repetitively in different scenarios and mean different things.
So what is one good way to clarify what you mean on something that can be taken 2 different ways?
Write it out fully the first time followed by the abbreviation or acronym in parenthesis, then use the abbreviation or acronym after that so long as it holds the same meaning throughout the report
What is best practice when taking/reporting times on your report?
Use the same clock/device to record your events.
If this is not possible, try to synchronize all your clocks. If synchronization doesn’t happen then record in your report what events were recorded with what clock so the inconsistencies are at least explained
The time you record on your Pt are considered to be _____?
The official times of the incidents/events
What things should you record timewise? (8)
PCR typically has spots for:
- call recieved
- dispatch time
- scene arrival/departure
- hospital arrival/departure (time back in service)
but always include:
- time you arrived to Pt’s side
- time(s) vitals are taken
- med administration
- intervention usage
What should you record about your communications with the hospital, pre-arrival? (4)
- Record when you communicated with them
- what/when you discussed with online medical direction/doctor
- orders given by medical direction and their effect/implementation
- online physicians name (get their sig if possible)
What is the core/essence of your PCR?
your assessment and interventions
Documents _____ findings of/in your assessment. Even ones that are _____.
What are pertinent negatives?
Documents all findings of/in your assessment. Even ones that are normal.
Pertinent negatives are discoveries of the absence of an expected symptom/sign
(ex. no loss of motor or sensory function on a broken leg)
Also important to a PCR is the statements given by witnesses, bystanders, and Pt. These can help establish _____?
MOI/NOI
Pts behavior (normal/abnormal)
Events leading up to
any first aid or medical care given before arrival
Always document your Pt or bystander/family statements as _____?
Direct quotes when possible
What type of things can you document about additional resources on scene?
When they arrived/who showed up and how they participated
5 elements of a good documentation?
- completeness and accuracy
- legibility
- timelessness
- absence of alterations
- professionalism
When present you should always complete the _____ and the _____ of your report with consistency.
narrative and check boxes
You should always avoid writing your report _____? (When) and for what 2 reasons?
When should you write your report?
Do not write report on the ambulance on the way to hospital, 1 because a bumpy ride makes for sloppy hand writing and 2 because your time and attention should be towards the Pt.
You should write your report as soon as possible AFTER you complete the emergency call
What should you do if you make a small error on a report and you catch it quickly?
What if it is a bigger mistake that you catch later?
What do you do if you remember something you want to add to a report after you already submitted it?
If it is small mistake, quickly caught, you can strike your pen through it and initial it and put in the correct info.
(DO NOT try to cover up the mistake or black out/scribble over it)
If it is a bigger mistake caught after you write the whole narrative or if it is something you want to add later after submission then you should make an ADDENDUM and submit it to be attached to the origian report
What should an addendum to a report include?
Date and time addendum was written, reason it was written, and the pertinent info
Never use _____ (3) in a report. You should only include _____. (professionalism)
Never use slang, biased statements, or irrelevant opinions. Only include relevant information
What are the 3 parts of a full narrative and what do they inlcude?
- Subjective : any info you get through a history
- Objective : any data derived through an assessment(head to toe or body systems)
- Assessment/Management plan : Document your field impression and your full management plan for your Pt based off it (includes ongoing assessment and your Pt status at hand off as well)
What are the two types of objective narratives?
- Head to toe (documents findings from head to toe ; this is normally used by EMS as it follows suite with a full physical exam)
- Body Systems (documents based off body systems instead of regions, like if a Pt as a severe asthma attack you would more document their respiratory system rather than GI)
What are the 4 general narrative format types?
- SOAP
- CHART
- Pt management (used for critical Pts and is a chronological list of events that happened starting at arrival
- Call incident (used for critical traumas with significant mechanism of injury)
What does SOAP stand for?
Subjective
Objective
Assessment
Plan
What does CHART stand for?
Chief complaint History Assessment Rx (treatment) Transport
What are the two types of Pts who can refuse care?
- a Pt who isn’t that sick or injured and doesnt want to go to the hospital
- a Pt who you believe needs help but refuses, AKA Against Medical Advisement (AMA)
