Advanced Life Support: Chapter 4 - Documentation

Flashcards covering EMS documentation procedures, legal requirements, and standardized terminology as presented in Chapter 4.

Prehospital care report (PCR)

The most common type of record generated for each patient contact, which helps ensure a continuum of care and provides a medical record for legal and administrative purposes.

Minimum data set

The specific set of data recommended by the U.S. Department of Transportation (DOT) to be included on all PCRs to standardize information across the nation.

Pertinent negatives

Signs or symptoms that might be expected based on the chief complaint but that the patient denies having, such as a denial of pain after an automobile accident.

Triage tag

A basic medical information record attached to a patient during a multiple-casualty incident (MCI) to document chief complaint, vital signs, and treatment.

Continuity of medical care

The primary reason for high-quality documentation, providing a baseline of assessment and interventions for emergency department personnel.

Administrative uses of PCR

Information used for preparing bills, submitting insurance records, and contributing to EMS system statistics like response times.

Legal document

The status of the PCR in court, where it may serve as an essential element of defense for the EMT or as evidence in criminal and civil lawsuits.

Educational and Research uses

The use of PCR data by scientists to study intervention effects or by administrators to track patient conditions for training needs.

Evaluation and Continuous Quality Improvement

The process of reviewing PCRs to ensure EMTs are adhering to protocols and identifying needs for remedial or continuing education courses.

Medical oversight

The review of documentation to determine if EMTs are adhering to the set standard of care and protocols for their specific area.

Run report

An alternative name for the prehospital care report (PCR) used in various parts of the country.

Trip sheet

Another alternative name for the prehospital care report (PCR).

Written report format

The traditional PCR format combining check boxes, write-on lines, and narrative areas.

Computerized direct data entry report

An electronic PCR format where data is entered via laptops, tablets, or mobile devices and synchronized with a central database.

Electronic clipboard

A pen-based computer system that recognizes handwriting or offers selection lists for electronic data entry.

If it wasn't written down, it wasn't done

A basic rule of documentation stating that if an action is not recorded, there is no proof or communication that it occurred.

If it wasn't done, don't write it down

A rule of documentation prohibiting the falsification of information on a PCR.

Standardization of PCR data

A DOT initiative to allow meaningful comparison and analysis of data from various EMS systems to improve medical methods.

AVPU

The mnemonic used to document a patient's level of responsiveness in the minimum data set.

Skin perfusion requirement

The recording of capillary refill as part of the minimum data set for patients less than $6$ years old.

Blood pressure requirement

The recording of blood pressure as part of the minimum data set for patients greater than $3$ years old.

Patient demographics

Information including age, sex, race, and weight required in the narrative and administrative sections of the PCR.

Administrative Information (Minimum Data Set)

Data including the time the incident was reported, unit notified, arrival at patient, leaving scene, and arrival at destination.

Time of transfer of care

The specific administrative time recorded when patient responsibility is handed over to facility staff.

Synchronous clocks

The requirement that all timekeeping devices in an EMS system correspond exactly to ensure accurate timekeeping for events like cardiac arrest.

Run data

The section of the PCR containing unit numbers, crew names, and dispatch addresses.

Patient position

An important detail to record when documenting vital signs, such as whether the patient was supine, standing, or sitting.

Patient Narrative

The section of the PCR where EMTs provide a detailed, subjective, and objective account of the assessment and mechanism of injury.

Objective information

Measurable or verifiable data, such as a pulse rate or a visible physical sign.

Subjective information

Findings based on individual perceptions or interpretations, such as a patient's statement about feeling light-headed.

Sign

An objective observation made during the physical assessment.

Symptom

A subjective finding reported by the patient regarding how they feel.

Mechanism of injury

The description of how the patient was injured, typically recorded in the narrative section.

Chronological treatment order

The requirement to document all interventions in the order they were administered, including the time and the patient's response.

Universal Documentation Guideline

The emergency care protocol adapted from the NASEMSO National Model EMS Clinical Guidelines 2022.

NEMSIS

National EMS Information System; the organization responsible for submission requirements and data standardization in EMS.

Incident demographics

Data elements that include type of incident, location, dispatch information, and response resources.

Unit back in service date/time

A NEMSIS mandatory field documenting when a unit is available for another call.

Primary role of the unit

Documentation of whether a unit is used for transport or non-transport duties.

PHI

Protected Health Information; patient-identifiable data that is generally excluded from CPI reviews but used for billing.

ICD-10

The coding system used for values such as Cause of Injury or Clinician Impressions in modern electronic PCRs.

Stroke/CVA last known well

The specific timestamp required to record the last time a stroke patient was observed in their normal condition.

Utstein Criteria

A set of reporting standards for cardiac arrest data elements used to enhance survival registries.

CARES

Cardiac Arrest Registry to Enhance Survival; a registry used to identify incident location types and outcomes for cardiac events.

Clinician's primary impression

The field working diagnosis for the most acute problem presented by the patient.

Initial patient acuity

The assessment of patient severity intended to be recorded prior to the delivery of EMS care.

Capacity assessment group

A set of data fields used to support documentation for patient refusal of care or transport.

Stroke score group

Data collected including facial droop, arm drift, speech, and unilateral weakness during a neurological assessment.

Reperfusion checklist

A documentation tool used to determine eligibility for stroke-related treatments, though use varies by service area.

GCS-qualifier

A specific element in the Glasgow Coma Score vitals group used to clarify the total score.

Mean arterial pressure

An additional vital sign option represented in high-level patient care reports, often calculated from systolic and diastolic values.

EtCO2

End-tidal carbon dioxide; a vital sign documented to monitor respiratory effort and ventilation quality.

Medication qualifiers (PN)

Pertinent negative options for medications, such as 'contraindication noted' or 'medication already taken.'

Vascular access location

A required data point when documenting procedures related to IV therapy.

Role of the Narrative

To 'paint the picture' for others to understand facts that do not fit into fixed data fields.

Medical Narrative format

An intuitive documentation style where the clinician tells the story from start to finish.

Improved (Medication Response)

When a medication has its intended therapeutic effect and patient symptoms decrease.

Unchanged (Medication Response)

When a medication has no intended therapeutic effect but the patient's condition does not deteriorate.

Worse (Medication Response)

When a patient's condition deteriorates because a medication was ineffective or the wrong medication for the situation.

Improved (Procedure Response)

When a procedure, like defibrillation, resolves the immediate problem into a desired outcome.

NEMSIS Version 2.2.1

The older data standard adopted in 2006, which NEMSIS stopped accepting on $12/31/2016$.

NEMSIS Version 3.4

The standard dataset and standard released in March 2015, which became the only standard as of August 2021.

Mandatory fields

Fields that require real data and do not accept nil values or pertinent negatives for the record to be stored.

Required fields

Fields that must be completed but allow nil values or pertinent negatives to be entered.

Not values (NV)

Attributes like 'not applicable' or 'not recorded' used to clarify a null entry in a NEMSIS element.

Nil values

Blank values in a data field, reflecting either an accidental omission or a purposeful lack of entry.

NEMSIS Element numbering

A structure reflecting the dataset and group name, such as 'eVitals.06' for systolic blood pressure.

Proper terminology and spelling

A requirement to use medical dictionaries to avoid mistakes that could cause treatment delays or errors.

Confidentiality

The legal right of the patient to have their medical information protected from unauthorized individuals.

HIPAA

The Health Insurance Portability and Accountability Act of 1996, which mandates limitations on the release of patient information.

Release of PCR information

Permitted by law for continuing care, criminal investigations, third-party billing, or legal subpoenas.

Refusal of treatment sign-off

The process of obtaining a signature from an adult with capacity who chooses not to accept medical care.

Informed decision-making

The responsibility of the EMT to ensure a patient understands the consequences, including potential death, of refusing care.

Persuasion toward hospital

The final effort an EMT should make before leaving a scene where a patient is refusing transport.

Consultation with medical direction

A step in refusal cases where a physician's opinion may change the patient's mind or provide guidance for on-scene care.

Refusal-of-care witness

A family member, police officer, or bystander who signs the PCR to verify a patient's refusal.

Limited legal worth of waivers

The concept that a signed refusal form does not replace the need for thorough, objective documentation.

Falsification of PCR

A prohibited act that can lead to license revocation, criminal charges, and compromise of patient care.

Medicare fraud and abuse

Exaggerating a patient's condition on a PCR to seek higher reimbursement, violating the False Claims Act.

Correcting a written error

The process of drawing a single horizontal line through the mistake, initialing it, and writing the correct information beside it.

Amending a submitted report

Drawing a single line through the error in a different color ink, adding a note with the correct info, initials, date, and time.

Transfer-of-care report (Drop report)

An abbreviated form containing minimal patient data and a signature left at the hospital when a unit must return to service immediately.

Special reports: Suspected abuse

Documentation required when an EMT encounters potential child or elderly mistreatment.

Special reports: Occupational exposure

Documentation needed if an EMT is exposed to infectious diseases like meningitis, hepatitis, or HIV.

SOAP

A documentation mnemonic standing for Subjective, Objective, Assessment, and Plan.

S (SOAP)

Subjective; information the patient tells you, such as 'I have terrible head pain.'

O (SOAP)

Objective; measurable signs identified in the physical exam through inspection, palpation, or auscultation.

A (SOAP)

Assessment; the field impression or general idea of the patient's condition formed by the EMT.

P (SOAP)

Plan; the defined action or emergency care provided to the patient.

SOAPIE

An expanded SOAP mnemonic where 'I' stands for Intervention and 'E' stands for Evaluation.

CHART

A documentation mnemonic standing for Complaint, History, Assessment, Rx (Treatment), and Transport.

H (CHART)

History; the section containing the patient's medical history, including the SAMPLE history.

T (CHART)

Transport; documentation of changes in patient condition en route and the type of transport provided.

CHEATED

A complex documentation mnemonic: Chief complaint, History, Exam, Assessment, Treatment, Evaluation, Disposition.

E (CHEATED)

Exam; specific information found during the physical examination of the patient.

D (CHEATED)

Disposition; the final transfer of care at the medical facility to another provider.

Medical Necessity

A standard required by insurance, Medicare, and Medicaid to justify transport by ambulance over other means.

Prudent layperson standard

A determination of necessity based on whether an average person would think the situation was an emergency.

Medicare coverage requirement

Stated in 42 \text{ CFR } .40(d), covering ambulance services only if other means of transport are contraindicated.

ET3 Payment Model

A pilot program (Emergency Treat, Triage, and Transport) designed to reduce emergency department use and reimburse for on-scene care or telehealth.