DOCUMENTATION:

1
DOCUMENTATION

• A Necessity of EMS

2
Objectives

• Explain
• Who needs a PCR
• Why documentation is necessary
• The core and minimum standards for documentation
• Three methods of EMS documenation
• Relate the preliminary PCR to the digital PCR,
  explaining the purpose and when to use
• Define the standards for
• Documenting a gross Cranial Nerve exam
• Documenting a Gross Motor exam
• Documenting the Drug Awareness (Drug Recognition)
  Exam
• Explain when/how to use EMTs to document refusals

3
Who Needs A PCR?

• Section 13 Patient Defined
• A patient shall be defined as
• Any individual who activates EMS for themselves
• Any individual who identifies themselves as such
• Any individual for whom 9-1-1 is called on their
  behalf for suspected illness or injury
• Any individual with an injury or illness
• Any individual with a medical or traumatic
  complaint
• Any individual with a new altered level of
  consciousness

But what about alcohol on board?
4
Assessment of the Intoxicated Person Section 22

• Perform a physical exam to rule out the presence
  of any sign of trauma
• Assess mental status
• Assess gross motor/sensory function
• Assess gross cranial nerve II-XII function
• Conduct D.A.R. (Drug Awareness Recognition)
  7-step Process
• Obtain VS

5
Assessment of the Intoxicated Person Section 22

• If the patient is oriented and the following are
  present
• Speech slurred but words are understandable
• Horizontal nystagmus may be present
• Able to ambulate on two feet without help
• No MOI, no complaint and or signs/symptoms of
  injury or illness
• No other substance finding

• These findings indicate low
• risk and this person may go
• to jail or home with a sober
• person to watch them.

6
Assessment of the Intoxicated Person Section 22

• If the patient is oriented or altered and any of
  the following are present
• MOI or signs/symptoms of minor injury (such as a
  small abrasion)
• Other substance abuse as indicated by the D.A.R.
  Process
• Systolic BP is 140 or
• HR is 90

• This person has a higher
• risk, consult with ED or
• transport.

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Why Document?

• LEGAL
• Avoid lawsuits, negligence, abandonment vs
  refusals
• COMMUNICATE MEDICAL INFORMATION
• ER, PCP, Surgeons
• QUALITY ASSURANCE
• Agency Review, Teaching, Peer Review, Recognition
  as a Profession
• STATE REQUIREMENT

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The Core of Documentation

• What did they tell you?
• What did you see?
• What is/are the problem(s)?
• What is/are the solution(s)?

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Minimum Standards

• Identifying Information
• What Happened
• Description of Symptoms Pertinent History
• Pertinent Exam
• Treatment Initiated
• Response to Treatment
• Events During Transport

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Description of Documentation Methods
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Combining the Methods
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Events and Symptoms

• What Happened?
• Prior to EMS activation
• Describe accidents
• OPQRST

• Pertinent Symptoms
• Pertinent Positives
• Pertinent Negatives

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Pertinent Positives and Pertinent Negatives

• Pertinent Negatives
• Items that exclude one of the differential
  diagnoses
• Can be symptoms, signs, tests, or response to
  treatment
• most often includes negative symptoms
• i.e. no SOB makes CHF unlikely
• i.e. no trauma makes a fracture unlikely

• Pertinent Positives
• Items that exist that support the diagnosis
• Can be symptoms, signs, tests
• i.e. glucometer value),
• or response to treatment
• i.e. ? BP ? P after fluid bolus

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Important Past Medical History Components

• The P in SAMPLE...
• Major Medical Hx cardiac, HTN, DM, CVAs
• Surgical Hx
• past 6 months
• abdominal surgeries for CC of abdominal pain
• cardiac for CC of chest pain, SOB
• trauma or obstetric for CC of SOB, CP, DVT

• Immunizations?
• Social Hx
• Alternative drugs (herbals)
• Recreational Drugs, EtOH
• Daily Diet
• Sexual History as pertinent to the chief
  complaint, such as the female of child bearing
  age who has abdominal pain

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Physical Exam

• PHYSICAL EXAM
• Trauma Patient
• Initial Impression
• Primary Survey and Key Interventions
• Trauma-Based Secondary Survey (pertinent
  negatives)
• VS, LOC
• HEENT
• CHEST
• ABD
• PELVIS
• EXT

• Physical Exam
• Medical Patient
• Initial Impression
• Primary Survey and Key Interventions
• Medical-Based Secondary
• VS, LOC
• CHEST
• ABDOMEN
• EXT
• NEURO

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Physical Exam

• Physical Exam
• Pertinent Positives
• Pertinent Negatives
• Positives and Negatives should relate to the call
• (ie no flail segments does not relate to a
  stroke unless they fell)

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Treatment Transport

• Treatment Initiated
• Medications
• Stabilization
• Transport method

• Response to Treatment
• What they tell you
• breathing easier
• PAIN SCALE
• What you assess
• lung sounds- decreased rales
• patient became tachycardic
• Changes in Treatment
• withheld atrovent
• gave additional pain meds

18
Special Cases

• Refusals
• Include
• Events
• Chief Complaint
• Physical Exam!!!
• Mental Status, VS, Head-to-Toe
• Signature of Understanding
• Potential Risks

• AMAs
• Include
• All Refusal Information plus
• Impression
• Call In to ED
• Discussion with Patient of Risks

19
Special Cases

• CN II-XII
• Include
• Positives/Negatives
• Gross Motor
• Include
• Positives/Negatives

• Drug Recognition Exam
• Include
• Pupil movement/reaction
• Romberg multi-task/time test
• VS (P BP)

20
Items to Avoid

• Opinion Statements I dont think he really
  passed out
• Judgmental Statements patient obviously drunk
• Unrecognized Abbreviations
• The terms alcohol on breath, non-cardiac chest
  pain, etc.

21
Items to Include

• ECG is attached to PCR
• On white copy (permanent record)
• On yellow copy (QA copy)
• Pertinent data
• Pt Name, Times, Dates, PCR, Mileage
• Face sheet
• If out of normal delivery area
• Such as Platte Valley, NCMC, North Suburban

22
Preliminary PCR (or PPCR)

• RETAC Project
• Less than 35 of PCRs are left at the hospital
  within 24 hours of pt delivery
• MVFPD 90 at all hospitals
• 50 are missing necessary information
• Date, address, mileage, pt. name, times, etc.

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PPCR

• Leave in ED
• A temporary document
• ePCR emailed or faxed in when completed

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PCR Review

• Is it legible?
• Does it follow a pattern?
• Is it accurate?
• Does it meet minimum standards?
• Would you feel comfortable with this as your
  supporting document in court???

25
Reminders

• John Michael will be coming later this month to
  talk about documentation using the narrative
  section of the ePCRs.
• Dr. Kanowitz will be here to help with the
  review, specifically refusals and using EMTs.
• Any other questions, please let Twink know