Patient Care Documentation

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Patient Care Documentation

• A Proactive Approach
• - Richard W. Patrick, B.S., EMT-P/FF
• - Steven A. Forry, EMT-P

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Objectives

• State the importance and benefits of professional
  patient care documentation.
• Understand the importance of following treatment
  protocols and standing orders.
• Differentiate the criminal, civil, and ethical
  implications of patient care documentation.

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Objectives Cont

• Understand the responsibility to properly assess,
  treat, stabilize, transport, and document the
  care provided to their patient, as identified in
  their scope of practice and within their standard
  of care.
• Develop a methodology for obtaining objective and
  subjective patient care information using open
  and closed ended questions.
• State the differences in civil, criminal, and
  possibly punitive aspects of alleged malpractice.

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Objectives Cont

• Recognize the value of prospective, concurrent,
  and retrospective continuous quality improvement
  through positive rather than negative
  reinforcement and disciplinary action.

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Identifying the Problem

• Trip Sheet
• Vs.
• Patient Care Report

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Scenario 1

• 53 y/o male, c/o SOB
• PMH CHF
• MEDS Lasix
• Allergies None
• Vital Signs
• 162/88, P-112, R-38
• 168/90, P-124, R-36

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Identifying the Problem

• Coupled to the need for quality patient care is
  the need for appropriate and thorough
  documentation of your findings

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Identifying the Problem

• a properly completed PCR can prevent a
  prehospital care provider from being sued, or, in
  the event that an incident is litigated, can
  dramatically improve the providers chances of
  winning the lawsuit.
• - Richard A. Lazar, JD
• - Robert J. Schappert III

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Identifying the Problem

• if the EMS training institutions have failed to
  adequately teach EMT students to document, they
  likely have also failed to establish standards
  for the profession of prehospital care.
• - The American College of Emergency Physicians

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Bad Trip Sheet

• Identify the problems.

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Bloopers

• Patient is able to remove his neck, but it does
  cause some discomfort.
• Patient has two teenage children but no other
  abnormalities
• Explained to the family that patient was at
  deaths door and we were trying to pull him
  through
• Patient suffered cardiac arrest. Resuscitation
  attempts failed and patient pronounced dead.
  Patient requests an autopsy.
• Skin Somewhat pale, but present.
• On the second day, the knee was better, and on
  the third day, it had completely disappeared.

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Patient Assessment Documentation

• Illness Assessment
• Head to Toe
• Injury Assessment
• Head to Toe
• Acronyms

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Patient Care Documentation

• PCR must be completed on every call
• PCR must be complete for every call
• Proper abbreviations, words, and attitude
• Readable, professional, and adequately reflect
  the care given or offered to patient

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Patient Care Documentation

• Quotes where appropriate and required
• Copy given in receiving hospital for attaching to
  permanent medical record.
• Refusal form and incident report completed

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If you didnt write it,

• you didnt do it!

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Patient Refusals

• First we must understand that a competent adult
  has the right to refuse treatment and/or
  transportation.

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Patient Refusals

• The EMS Providers Challenge
• To distinguish incompetence from bad
  decision-making.

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Patient Refusals

• Patients who request to sign AMA
• Patients who are allowed to sign AMA
• Patient requests treatment - but no transport
• Patient requests transport - but no treatment

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Patient Refusals

• Patients who should go to a hospital
• Patients who must go to a hospital
• Patients with life threatening illness/injury

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Patient Refusals

• The EMS provider must always keep the best
  interest of the patient at the forefront

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Refusal Information Sheet

• A document that provides information to the
  victim/patient regarding their refusal of
  services and offers added protection to the EMS
  provider.

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Refusal Check List

• This check list is used to assist the EMS
  provider in a systematic approach to assure all
  venues have been exhausted during the
  consideration of patient refusals.

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Patient Evaluation Sheet

• The EMS Cognitive Evaluation sheet assists with
  elements of perception in the determination of
  the victim/patients level of competence.
• Raise your right hand

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Service Transport Form

• Competent patients maintain the right to refuse
  medical care and/or transportation. This sample
  Refusal of Service/Transport form builds from
  previous examples to aid EMS providers when
  attempts to treat/transport have been exhausted.

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The Patient Care Report

• Misspelled words, illegible hand-writing, and
  poor writing skills lend themselves to
  questioning the credibility of the care provider
• Just the Facts Maam

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Scenario 2

• 76 y/o female c/o chest pain, nauseated, and
  dizzy.
• PMH Angina, Gall Bladder Operation
• MEDS Nitro, ASA, Vitamins
• Allergies PCN
• Vital Signs
• 204/98, P-56, R-28
• 198/92, P-52, R-24

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Sample Patient Care Report Form

• Although Patient Care Report forms vary in
  design, content is often the same. Several PCRs
  are available for review and discussion.

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Scenario 3

• 26 y/o male walking around acting inappropriately
  post MVA.
• Victim is bleeding from head.
• Possible alcohol consumption
• PMH unknown
• Vitals Victim does not permit V.S. to be taken.

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Patient Care Report Form

• Upon call completion, fill out your PCR and any
  applicable documents.

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EMS Report Form

• The PCR provides important data for EMS
  Operations!

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Scenario 4

• 66 y/o male c/o tightness in his chest.
• He permits Rx but refuses Tx.
• PMH Angina, Gall Bladder surgery 10 years ago.
• Meds Nitrostat, ASA
• Allergies MS
• Vitals
• 188/98, P-116, R-24

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Incident Reports

• Treatment Errors
• Equipment Malfunctions
• Medical Devices Act
• Domestic Situations
• Vehicle Malfunctions/Crashes
• Other
• Infectious Disease Exposure, etc...

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Incident Report Form
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Medical Direction

• Medical Direction is not only a necessity but an
  asset to any EMS organization.

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Medical Direction

• On - Line Medical Direction
• vs.
• Off - Line Medical Direction

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The Quality Process

• Quality Assurance
• Continuous Quality Improvement

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The Quality Process

• EMS personnel should consider the Quality Process
  as an intricate part of their everyday function.

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The Quality Process

• The Seven Key Action Areas
• 1. Leadership
• 2. Information Analysis
• 3. Strategic Quality Planning
• 4. Human Resource Development and Management
• 5. EMS Process Management
• 6. EMS System Results
• 7. Satisfaction of Patients and Other
  Stakeholders
• -Malcolm Baldridge Quality Program

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Summary- What Can/Should We do?

• Prospective QA/QI
• Active Medical Director
• Peer performance reviews
• Regular case reviews
• Protocol review/testing

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Summary- What Can/Should We do? (cont)

• Computer based PCR w/ protocol compliance
• PCR reviews - staggered by length of experience
• Skills review testing

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If you didnt write it,

• you didnt do it!

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Dare To Be Different From Everyone Else!

• Do Whats Right!

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Questions AnswersTHANKS FOR SHARING
YOUR TIME !!