Documentation Charting

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Documentation /Charting

• Don Hudson, D.O.,FACEP/ACOEP

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Documentation

• Purposes
• Preserves basic patient information
• Records changes in patient condition
• Justifies treatment
• Allows continuity of care
• Satisfies regulatory requirements
• Provides data for quality control

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Documentation

• Protection for EMS personnel
• Reflection of good patient care

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Documentation

• An accurate, complete, legible medical record
  implies
  accurate, complete, organized assessment and
  management

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Documentation

• Characteristics of good medical record
• Accurate
• Complete
• Legible
• Free of extraneous information

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Accurate

• Document facts, observations only
• Do NOT speculate about patient or incident
• Double-check numerical entries
• Recheck spellings of
• Persons
• Locations
• Medical terms

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Accurate

• If you make a mistake, document it.
• It is better to record your own mistakes that for
  someone else to uncover them.

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Complete

• Include all requested information
• If information requested does not apply, note
  not applicable or N/A
• Include at least two sets of vital signs on every
  patient
• Failure to document implies failure to consider
• If you look for something and it isnt there,
  document its absence

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Complete

• IF IT ISNT DOCUMENTED,
  IT WASNT DONE!

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Legible

• If you cannot read the report, you may be unable
  to determine what happened
• Documents presented in court must speak for
  themselves
• If a document cannot be deciphered, the jury has
  to right to ignore it altogether

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Legible

• If the report is sloppy, others will assume that
  the care was equally sloppy

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Free of Extraneous Information

• Avoid labeling patients (drunk, psych
  patient)
• Describe the observations you made
• Preface comments made by the patient with per
  the patient or patient stated

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Free of Extraneous Information

• Record hearsay only if applicable
• Do NOT record hearsay as facts
• Use quotation marks only if a statement is
  accurate word-for-word

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Free of Extraneous Information

• Avoid interjecting humor
• The public does not regard EMS as a funny business

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Documentation

• A copy of the report must be left with the
  patient at the receiving hospital
• State law requires this
• Patient care has not legally been transferred
  until the receiving facility has your written
  report

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Documentation

• The person who rode with the patient writes the
  report
• All personnel who participated in care should
  review the report

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Documentation

• If something needs to be corrected, correct it
• The sooner an error is corrected, the more
  credible and reliable the change is
• Mark through information so it is still readable
• Then write in the new information and
  initial/date the change

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Documentation

• If you have a long report, dont hesitate to use
  additional pages

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Documentation

• Avoid stating diagnostic impressions
• Report facts and observations
• If you must state a diagnostic impression
• Do so within the scope of your training
• Include the observations that led to the
  impression

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Documentation

• Avoid using possible or ? when the
  observation would have been obvious to anyone

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Documentation

• Be sure treatments recorded match the mechanism
  of injury or the diagnostic impression
• If something should have been done that was not,
  state why

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Documentation

• If spaces are provided for documenting times,
  fill them in carefully
• Failing to document times implies lack of concern
  about the time factor
• If you have a prolonged scene time, say why

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Documentation

• If you put a monitor on the patient, a hard copy
  of the EKG should accompany the report

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Documentation

• If a patient complains of pain in a area, state
  what you found when you examined the area
• Failure to record your observations implies that
  you noted the complaint, but did not investigate
  it

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Documentation

• On MVCs, report
• Type of collision (head-on, roll-over, lateral
  impact, etc.)
• Degree of damage to vehicles
• Location of patients
• Use of seatbelts

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Documentation

• On falls report
• Where the patient fell from
• How far the patient fell
• The surface the patient fell onto
• Why the patient probably fell

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Documentation

• On head injuries report
• Level of consciousness
• Pupillary responses

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Documentation

• On head injuries report
• Presence/absence of
• Discharge from nose and ears
• Cervical pain, muscle spasm, tenderness,
  deformity
• Paresthesias
• Altered motor function
• Altered sensory function

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Documentation

• On chest injuries report
• Position of trachea
• Status of neck veins, breath sounds, heart sounds
• Presence or absence of
• Crepitus
• Subcutaneous air
• Paradoxical movement of chest wall

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Documentation

• On extremity injuries report
• Distal skin color and temperature
• Presence or absence of
• Distal pulses
• Motor function
• Sensory function

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Good Documentation is NOT C.Y.A

• Good Documentation is a Reflection of Good
  Patient Care