CH 6 Documentation

What is the purpose of EMS documentation?

It is an integral part of the patient care process and becomes part of the patient's medical record.

What does a PCR stand for?

PCR stands for Patient Care Report.

What must be included in a PCR?

Objective information, subjective information, and details of patient care.

What are the minimum requirements for a PCR?

PCRs must be complete, accurate, and legible.

What can omissions and errors in a PCR result in?

Errors in care, litigation, job loss, and poor reputation.

What should reports include regarding patient statements?

Reports may include subjective statements from the patient but cannot include bias or personal opinions.

What does HIPAA have to do with patient care reporting?

HIPAA has ramifications for patient care reporting, ensuring patient privacy.

What is the significance of documenting the patient's condition upon arrival?

It provides a record of the patient's condition and any changes during care.

What is the role of NEMSIS in EMS documentation?

NEMSIS stores standardized EMS data from each state to define EMS care.

What types of PCRs are commonly used in EMS?

Most EMS reports are electronic, with various designs including checkboxes and dropdown menus.

What is required for timely billing in EMS documentation?

Document procedures performed, obtain medical necessity signature, and document the reason for ambulance transport.

What is the minimum data set for every EMS call?

Standard items including run data and patient data must be documented on every call.

What information should be documented regarding the transfer of care?

Document who the patient was left with to avoid allegations of abandonment.

What should be documented when care is provided prior to arrival?

Obtain and document information on what care has been provided by dispatch, off-duty providers, or laypeople.

What rights do competent adult patients have regarding care?

Competent adult patients have the right to refuse care.

What are the consequences of sloppy documentation?

Sloppy documentation implies sloppy care and can lead to negative outcomes for the provider.

What is the importance of documenting treatments and their effects?

It provides a record of the treatments given and any changes in the patient's condition.

What should be included in the objective observations of a scene?

Document objective observations, treatments, effects of treatments, and changes in the patient's condition.

What is the purpose of incident reviews and quality assurance in EMS?

PCRs may be requested for medical audits and educational activities to improve care quality.

What is the significance of documenting demographic information in a PCR?

It helps in understanding the patient's background and tailoring care accordingly.

What types of information are included in run data?

Incident times, locations, and responding units/crew member names.

What is the role of subjective information in a PCR?

Subjective information provides insight into the patient's perspective and condition.

Why is it important to accurately document skills attempted and performed?

It ensures accountability and reflects the care provided during patient interactions.

What should a patient know regarding their care?

The current situation, their right to receive or refuse care, and the consequences of refusal.

What must be documented when a patient refuses care?

The information must be given in a language the patient understands, documented on the PCR, witnessed by an observer, and initialed and signed by the patient.

What should be documented if a patient is transported against their will?

The reason for transporting, the means of transportation, if the patient was restrained, and if the patient was coached verbally or coerced.

What is implied consent in medical treatment?

Unresponsive patients may be treated under implied consent.

What should you do if you disagree with a patient's refusal of care?

Document all contacted parties on the PCR, have a witness to the refusal, evaluate the patient's mental status, and remind patients they can call EMS later.

What is essential to document in a PCR narrative?

The narrative should be detailed, accurate, complete, and specific, documenting consultations, orders from medical control, and refusal situations.

What are the preferred methods for narrative documentation?

Chronological order, SOAP method (Subjective, Objective, Assessment, Plan), CHARTE method (Chief complaint, History, Assessment, Treatment, Transport, Exceptions), and body systems/parts approach.

What should be avoided in PCR documentation?

Jargon, slang, personal opinions, and anything libelous.

What are the consequences of poor documentation?

Inappropriate, inaccurate, and insufficient documentation can adversely affect patient care and have legal implications.

What steps should be taken if a revision to a PCR is needed?

Note the date and time of revision, include the purpose for correction, and never discard the original report.

What is the importance of accurate timekeeping in documentation?

Accurate timekeeping is essential for tracking call times, dispatch, arrival at the scene, time with the patient, medication administration, and transfer of care.

What should be included in a properly written report?

The report should be complete, concise, legible, written in ink, neat, and easy to read.

What is the significance of documenting workplace injuries?

OSHA guidelines require workplace injuries to be logged, and companies may require additional documentation.

What should be done with reports after they are completed?

Reports should be placed in a secure location and completed in a timely manner.

What is the SOAP method in documentation?

The SOAP method stands for Subjective information, Objective information, Assessment, and Plan for treatment.

What does the CHARTE method stand for?

The CHARTE method stands for Chief complaint, History, Assessment, Treatment, Transport, and Exceptions.

What should be done if a report is lost?

Lost reports can have huge legal implications; ensure reports are complete and turned in on time.

What is the role of mutual aid services in multiple-casualty incidents?

Mutual aid services provide additional support during multiple-casualty incidents (MCIs).

What should be documented regarding controlled substances?

Follow the policy of the medical director regarding the documentation and handling of controlled substances.

What is the importance of proposing alternate methods of care?

Proposing alternate methods of care can help ensure the patient receives appropriate treatment even if they refuse initial care.

What should be included in the narrative section of a PCR?

The narrative should document all relevant details of the patient care encounter, including consultations and orders from medical control.

What is the recommended approach for documenting patient care?

Use one reporting method consistently and ensure proper grammar and spelling.

What is the significance of having a witness during a refusal of care?

A witness is necessary to validate the refusal and ensure that the patient was informed of the consequences.

What should be done if a patient is unresponsive?

Treat the patient under implied consent, ensuring all efforts are made for the patient's best interests.

What is the importance of documenting precautions taken and protective gear worn?

Documenting precautions and protective gear is essential for workplace injury reports and compliance with safety regulations.

What should be done with reports that are handwritten?

Handwritten reports should be legible, written in ink, and neat and easy to read.