Pre-Hospital Documentation

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Pre-Hospital Documentation

• Vermont Emergency Medical Services
• Last updated October 2006

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An Actual Run Form
Upon our arrival, found pt in bed with first
responders complaining of breathing difficulty.
Pt. physician saw her yesterday. Had cold X 2
weeks. Physician said lungs were congested.
Nauseated, no vomiting. Upon listening to lung,
equal but noisy. Pt initially put on 4 liters
nonrebreather, complained so we used 24 Venturi.
Allergic codeine. Dr. Bitlett. Pt diabetic due
for insulin 800. Meds insulin.
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An Actual Run Form
Upon our arrival, found pt in bed with first
responders complaining of breathing difficulty.
Pt. physician saw her yesterday. Had cold X 2
weeks. Physician said lungs were congested.
Nauseated, no vomiting. Upon listening to lung,
equal but noisy. Pt initially put on 4 liters
nonrebreather, complained so we used 24 Venturi.
Allergic codeine. Dr. Bitlett. Pt diabetic due
for insulin 800. Meds insulin.
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Session Goal

• At the end of this session, the student will be
  able to use the Vermont EMS Incident Report Form
  to document a pre-hospital call in a systematic
  and complete fashion.

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Learning Objectives

• At the end of this session, the student will be
  able to
• describe the SOAP or CHART method of charting
• 2. list at two principles of writing a narrative
• 3. describe the role of documentation when a
  patient refuses care or transport
• 4. describe how care administered to a patient in
  a multiple casualty incident is documented

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Learning Objectives

• 5. given pieces of information (in random order)
  about a call, properly document the assessment
  and treatment of the patient
• 6. describe the procedure to use when adding or
  correcting information on the run report form
  after the copies have been separated
• 7. (for Advanced EMTs only) list the pieces of
  information which should be recorded on the run
  report form when the EMT administers advanced
  life support in the field.

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What This Session Will Cover

• Importance Purposes of Documentation
• Frequent Problems (and Solutions)
• Completing the VT EMS Incident Report Form
• Exceptions and Special Cases
• Demonstration and Practice

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Purposes of Documentation

• educational
• properly done within HIPAA requirements
• administrative
• statistics and billing
• research

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Purposes of Documentation

• evaluation and critique
• What proportion of patients with a chief
  complaint of difficulty breathing receive high
  concentration oxygen?
• continuity of treatment in hospital

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Purposes of Documentation

• legal
• form is not evidence in itself
• becomes evidence as part of testimony of witness
  to authenticate it
• can be used to refresh the memory of a witness
• retain original for legal purposes

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Kinds of Errors

• incomplete or incorrect blanks and boxes (e.g.,
  date)
• SOLUTION?
• have someone else check the form

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Kinds of Errors

• incomplete or incorrect narrative (e.g.,
  description of a patient's injuries without
  mentioning that he was in a collision
• SOLUTION?
• use an outline to remind yourself what
  information to include

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Kinds of Errors

• form reflects incomplete assessment or poor care
  
• SOLUTION?
• document extenuating circumstances
• combative patient
• language barrier
• pt refusal to cooperate
• extrication difficulties
• delay in response, at the scene, or en route to
  ED

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Kinds of Errors

• form reflects incomplete assessment or poor care
  
• SOLUTION?
• if deviation from the usual treatment protocols
  occurred, explain why do not try to cover up
  errors or omissions in care

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The Vermont EMS Incident Report Formor Patient
Care Report (PCR)
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PCR Demographic Info
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Code 2/Code 3

• Any use of lights OR siren Code 3

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Nature of Call/CC

• Fill in the chief complaint or nature of call as
  found, not as dispatched

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Treatment Vital Signs
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Level of Treatment Transport

• Fill in treatment based on what the agency
  completing the form did for the pt
• Fill in transport based on treatment the pt is
  receiving, regardless of who gives it

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(No Transcript)
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Trauma Score

• Complete for trauma patients only
• Use information from earliest EMS assessment
• Let the hospital worry about adding up the numbers

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Vital Signs

• Repeat VS frequently
• Put SpO2, blood glucose, etc. in comments

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Vital Signs

• As needed, draw lines to make additional boxes
  for vital signs

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A System for Comments

• S
• O
• A
• P

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The SOAP System

• Subjective
• Objective
• Assessment
• Plan

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Another System for Comments

• C
• H
• A
• R
• T

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The CHART System

• Chief complaint
• History
• Assessment
• Rx (treatment)
• Transport

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SOAP

• Subjective
• Chief Complaint (CC)
• History of Present Illness (HPI)
• Past Medical History (PMH)

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Subjective/History

• History of Present Illness (HPI)
• O
• P
• Q
• R
• S
• T
• U

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Subjective/History

• History of Present Illness (HPI)
• Onset
• Provokes
• Quality/Quantity
• Region/Radiates
• Severity
• Time
• Undo
• associated symptoms

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Subjective/History

• Past Medical History (PMH)
• M A
• A M
• I P
• D L
• S E

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Subjective/History

• Past Medical History (PMH)
• Medications Allergies
• Allergies Medications
• Illnesses Pertinent past history
• Doctor Last oral intake
• Surgery Events leading to illness or injury

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Objective/Assessment Trauma

• pt appearance, position and surroundings
• head, eyes, ears, nose, throat
• neck
• chest
• abdomen and pelvis
• extremities

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Objective/Assessment - Cardiorespiratory

• pt appearance, position and surroundings
• neck jugular veins
• chest lung sounds
• extremities pedal edema
• other oxygen saturation, EKG as appropriate

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Objective/Assessment Altered Mental Status

• pt appearance, position and surroundings
• mental status
• AVPU
• orientation
• memory
• loss of consciousness

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Objective/Assessment Altered Mental Status

• pupils
• trauma exam, including movement of extremities
• other
• blood glucose
• oxygen saturation, EKG as appropriate

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Exercise 1

• In the first blank for each phrase, indicate
  what kind of information is given by using Hx for
  history and PE for physical exam.

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Principles of Narrative Comments

• Include pertinent negatives.
• If a pt c/o chest pain, document the presence or
  absence of .

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Principles of Narrative Comments

• Include pertinent negatives.
• If a pt c/o chest pain, document the presence or
  absence of difficulty breathing.

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Principles of Narrative Comments

• Include pertinent negatives.
• If a pt c/o chest pain, document the presence or
  absence of difficulty breathing.
• If a pt c/o a blow to the head, document whether
  or not the pt .

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Principles of Narrative Comments

• Include pertinent negatives.
• If a pt c/o chest pain, document the presence or
  absence of difficulty breathing.
• If a pt c/o a blow to the head, document whether
  or not the pt lost consciousness.

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Principles of Narrative Comments

• Describe, dont conclude.
• A well known, unshaved, unkempt, foul-smelling,
  slightly cyanotic, 62 y/o alcoholic gentleman was
  carried into our emergency room by three million
  lice, all screaming, Please save our host.
• - from an actual doctors note shown to a
  jury in a malpractice suit in 1977

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Principles of Narrative Comments

• Describe, dont conclude.
• Pt had slurred speech, frequent mood swings
  between happy and combative, inability to walk
  without assistance and odor of alcoholic beverage
  on his breath.
• Is there any need to say this pt was drunk?

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Principles of Narrative Comments

• Record important observations about the scene.
• Suicide note found next to pt

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Principles of Narrative Comments

• Avoid radio codes on the form.

Code 11, 33, 55, 77
In the 1970s in some parts of Vermont, this
meant Code 11 emotional disturbance Code 33
overdose Code 55 alcohol intoxication Code
77 attempted suicide
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Principles of Narrative Comments

• Use only standard abbreviations.
• NOT, for instance
• CTD
• (circling the drain)
• HIBGIA
• (had it before, got it again)
• FTD
• (fixing to die)

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Principles of Narrative Comments

• Include changes in the patients condition after
  treatment or while en route.
• After 1 tube of oral glucose, pt became lucid and
  thanked us profusely.

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Principles of Narrative Comments

• Identify the source of information when it is not
  the patient.
• Per wife, pt has used cocaine for 2 years.

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Spelling

• medication names

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Spelling

• orient
• orientate

X
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Spelling

• clavicle
• clavical

X
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Spelling

• dilated
• dialated

X
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Spelling

• crepitus
• crepidus

X
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Spelling

• prostate
• prostrate

X
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Spelling

• palpitation
• palpation

X
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Spelling

• seize
• seizure

(verb)
(noun)
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Spelling

• diaphoretic
• sweaty

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Punctuation
Who says punctuation doesnt count?
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Punctuation
Pt experiences difficulty swallowing tires
easily. OR

• Pt experiences difficulty swallowing, tires
  easily.

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Punctuation
She moves her bowels roughly, three times a
day. OR

• She moves her bowels roughly three times a day.

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Confidentiality

• Health Insurance Portability and Accountability
  Act (HIPAA) Privacy Rule
• Its not just the form thats confidential, but
  the medical information about the patient.
• HIPAA applies whenever your service bills a pt.
• Even if a pt doesnt get a bill, the EMS agency
  and providers are expected to maintain
  confidentiality.

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Exceptions and Special Cases

• Multiple Casualty Incidents
• Refusal of Care

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Multiple Casualty Incidents

• Use Met-Tags or local approved equivalent
• Standard of care for documentation is different
  in an MCI

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MCI

• In an MCI, fill out tag as completely as
  circumstances allow
• Afterward, use tag to complete PCR the best you
  can

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Refusal of Care

• Vermont Supplemental Report for Patient
  Non-Transports
• to be used with non-transport protocol
• to be completed in addition to PCR
• available free from EMS Office

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Refusal of Care
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Refusal of Care
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Refusal of Care
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Refusal of Care
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Refusal of Care
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What About Other VT EMS Forms?

• VT EMS no longer collects
• Cardiac Arrest Report Forms or
• Esophageal Tracheal Combitube Forms
• Follow district medical advisors directions
• Both forms are available free of charge from VT
  EMS Office

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Learning from Others Experience

• Evaluate the following narratives and describe
  how they could be improved.
• Note Information has been typed for ease of
  reading, but these are actual forms.

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Example 1
(20 y/o female)
Pt has not been feeling well X 1 day. At 400 am
this date pt started vomiting and uncontrollable
bowels. Aching in both arms shoulders. Pt had a
temp. of 39.1 at this time. Pt has taken Datril
one at 0116 and again at 0430 this am. No meds.
No doctor. No allergies

• 88 98/60 20
• 1009 124 80/Dopp 17

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Example 1

• Strengths?
• two complete sets of VS en route to hospital

• Improvements?
• disorganized
• skimpy (what was the chief complaint?)
• recognize and treat shock when your patient has it

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Example 2
1450 R/L KVO 16 ga LAB
R compound open femur fracture. Lacerations
inner R thigh, R ankle, R toes, R little toe
underneath. Abrasions both elbows, 4 burn marks
1 ½ diameter in thoracic/lumbar region of back.
femur fracture w/ bone coming thru medial aspect
approx 3 above knee. Open wound approx 3 long
lateral aspect approx 2 above knee 1 open wound
with great deal of bleeding from medial aspect of
wound. Contusions lacerations to tib/fib area
of R leg. Pt. has good motor function of the toes
on the R leg and good distal pulse. Pt drowsy and
difficult time getting radial pulse. Pt had no
guarding in abdomen breath sounds good. NKA,
NKM. Pt took off helmet and jacket prior to
arrival.
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Vital Signs Example 2

• 56 84/P 80

Both legs of MAST inflated
1450 68 104/D
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Example 2

• Strengths?
• detailed descriptions of injuries
• recognized and treated shock

• Improvements?
• What happened (how was pt injured)?
• Pre-MAST vital signs?
• Was initial respiratory rate really 80 per minute?

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Example 3
68 y/o male found lying face down on bedroom
floor, had vomited. Pt responsive to verbal
stimuli, could answer questions with single
words, but could not tell us what happened or
speak understandably. Able to move all
extremities, oriented to person only. Large
contusion L forehead, small abrasion on R
forehead and upper bridge of nose. Pupils
constricted. Wife reports hx stomach problems but
was very upset, unable to give good history.
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Example 3

• Strengths?
• good description of abnormal mental status
• good explanation for lack of history

• Improvements?

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Example 4
Arrived to find alert oriented X 3 28 y/o female
c/o substernal pain that started approx 4 hrs ago
and has been constant. Pain radiated into back.
Skin warm, dry pink. Pain felt as something
heavy. Lungs clear equal bilaterally. Had
stress test earlier today results unknown.
Transported with 10 lpm NRB in Fowlers position.
M Axid. A N/A. I Mitral valve prolapse. D
McDonald. S 1988 Hysterectomy.
2000 108 128/96 24 2018 112
130/P 28
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Example 4

• Strengths?
• good description of history of present illness
• two complete sets of vital signs

• Improvements?
• nonstandard abbreviations

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Correcting Information

• Before form submitted
• if small error, draw single line through it and
  initial it
• agency may require date and time, too
• if large error, start new PCR
• Do NOT try to obliterate error
• appears EMT was trying to hide something

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Correcting Information

• After form submitted
• if information important, EMT who wrote PCR
  should use separate piece of paper to
• note reason for addendum and why it was not in
  original report
• note date and time of addendum
• describe additional or corrected information
• Attach to PCR
• On original form, write See addendum

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IV Fluids Medications
IV fluids
When a slash separates two words in a box, the
word to the left of the slash is for IV fluids
and the word to the right is for medications.
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IV Fluids Medications
Medications
When a slash separates two words in a box, the
word to the left of the slash is for IV fluids
and the word to the right is for medications.
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IV Fluids Medications
Remember to extend the box lines before writing
your narrative.
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Exercise 2

• Work in small groups and organize the information
  on the cards so that it fits the SOAP or CHART
  format.

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Summary

• Have a system for completing the PCR
• Have someone else check the form
• Beware spelling and punctuation pitfalls
• Use non-transport form when appropriate

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Questions?