Documentation JCCC EMT (EMS 132)

some reasons for documentation

continuity of care

admin use- billing and insurance, stats

legal use- crime victim, lawsuit

education and research

quality improvement

minimum data set and the 2 parts

the minimum stuff that must be on every PCR

clinical and admin.

the clinical minimum data set parts

CC

LOC

BP > 3 yo

skin condition and perfusion/ cap refill 

pulse (fast or slow at least)

RR and effort

age, sex, weight, race

administrative minimum data set

TOC (time on call)

dispatch time

PT contact time

transport time

time at destination

time of transfer of care

vital signs considerations

at least 2 sets

document the position they were in when taken

obtunded

AMS

HIPAA

health insurance portability and accountability act

when extra doc. is needed

abuse

EMS hurt

violence- depends

infectious disease exposure

needle sticks

an add on/later correction to a report

addendum- end with the date and your initials

refusals- how to convince

Tell them the truth

have someone else say it (family)

give alternative (can you take him? Uber?) 

Call us back

SOAP

subjective

objective

analysis

Plan

Important things to include in narrative

each time you moved the pt

anything they refused

pertinent positives and negatives

what you assessed and did not assess

CHAART

dispatch/scene and CC

history- SAMPLE, OPQRSTI,exp ?s, what others say

Assessment- what I check or see

Analysis- what I think it is. 2-3 rule outs R/O

Rx- treatment I gave with times.

Transport- how I moved the pt, where I took them and how

They cant refuse if… They must be

their decision making is altered by disease, injury, or mind altering substance

they must be alert, not confused, and able to understand the need for care and risk of refusing.