Patient Care Documentation - PowerPoint PPT Presentation

1 / 43
About This Presentation
Title:

Patient Care Documentation

Description:

Patient Care Documentation A Proactive Approach - Richard W. Patrick, B.S., EMT-P/FF - Steven A. Forry, EMT-P – PowerPoint PPT presentation

Number of Views:641
Avg rating:3.0/5.0
Slides: 44
Provided by: Arthu156
Category:

less

Transcript and Presenter's Notes

Title: Patient Care Documentation


1
Patient Care Documentation
  • A Proactive Approach
  • - Richard W. Patrick, B.S., EMT-P/FF
  • - Steven A. Forry, EMT-P

2
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.

3
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.

4
Objectives Cont
  • Recognize the value of prospective, concurrent,
    and retrospective continuous quality improvement
    through positive rather than negative
    reinforcement and disciplinary action.

5
Identifying the Problem
  • Trip Sheet
  • Vs.
  • Patient Care Report

6
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

7
Identifying the Problem
  • Coupled to the need for quality patient care is
    the need for appropriate and thorough
    documentation of your findings

8
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

9
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

10
Bad Trip Sheet
  • Identify the problems.

11
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.

12
Patient Assessment Documentation
  • Illness Assessment
  • Head to Toe
  • Injury Assessment
  • Head to Toe
  • Acronyms

13
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

14
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

15
If you didnt write it,
  • you didnt do it!

16
Patient Refusals
  • First we must understand that a competent adult
    has the right to refuse treatment and/or
    transportation.

17
Patient Refusals
  • The EMS Providers Challenge
  • To distinguish incompetence from bad
    decision-making.

18
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

19
Patient Refusals
  • Patients who should go to a hospital
  • Patients who must go to a hospital
  • Patients with life threatening illness/injury

20
Patient Refusals
  • The EMS provider must always keep the best
    interest of the patient at the forefront

21
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.

22
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.

23
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

24
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.

25
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

26
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

27
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.

28
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.

29
Patient Care Report Form
  • Upon call completion, fill out your PCR and any
    applicable documents.

30
EMS Report Form
  • The PCR provides important data for EMS
    Operations!

31
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

32
Incident Reports
  • Treatment Errors
  • Equipment Malfunctions
  • Medical Devices Act
  • Domestic Situations
  • Vehicle Malfunctions/Crashes
  • Other
  • Infectious Disease Exposure, etc...

33
Incident Report Form
34
Medical Direction
  • Medical Direction is not only a necessity but an
    asset to any EMS organization.

35
Medical Direction
  • On - Line Medical Direction
  • vs.
  • Off - Line Medical Direction

36
The Quality Process
  • Quality Assurance
  • Continuous Quality Improvement

37
The Quality Process
  • EMS personnel should consider the Quality Process
    as an intricate part of their everyday function.

38
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

39
Summary- What Can/Should We do?
  • Prospective QA/QI
  • Active Medical Director
  • Peer performance reviews
  • Regular case reviews
  • Protocol review/testing

40
Summary- What Can/Should We do? (cont)
  • Computer based PCR w/ protocol compliance
  • PCR reviews - staggered by length of experience
  • Skills review testing

41
If you didnt write it,
  • you didnt do it!

42
Dare To Be Different From Everyone Else!
  • Do Whats Right!

43
Questions AnswersTHANKS FOR SHARING
YOUR TIME !!
Write a Comment
User Comments (0)
About PowerShow.com