Documentation in Emergency Medical Services

Documentation and Record Keeping

Importance of documentation is emphasized, albeit without a slide, primarily for legal reasons and ensuring continuity of care.
Continuity of care involves ensuring a seamless transition of patient information and care between healthcare providers.

Record keeping is crucial; familiarity with FOIA (Freedom of Information Act) is expected.
FOIA implies accountability: documenting actions necessitates responsibility for those actions.

Documentation influences decision-making: knowing a report is required pushes providers to prioritize the patient's best interest.
Example: A scenario where a provider might choose a more beneficial treatment option due to the awareness of needing to document the decision-making process.
An anecdote about a colleague highlights documentation's impact on narcotic administration, driven by policy changes requiring more paperwork.
The importance of documenting why certain pain management options were not used is stressed, especially in cases of significant trauma.

Explanation of the purposes of a patient care report.
Description of the typical elements found in a patient care report, including the data set.
Discussion on the pronunciation of "data" and its relevance in professional settings.

Errors in PCRs are inevitable; the procedure for correcting them is important.
Errors can occur in the field and must be documented.
Personal anecdote about a medication error (Versed/midazolam) due to concentration changes is shared.
Old concentration: 5 \text{mg Versed} : 1 \text{mg saline}
New concentration: 10 \text{mg Versed} : 2 \text{mg saline}
Max dose is 5mg.
The importance of documenting errors is emphasized, along with potential consequences.
Tools used to document patient care in the field (splints, ice packs, c-collars, backboards, stair chairs, etc.).

Consequences for mistakes range from continuing education to license revocation.
Documenting mistakes is crucial; covering them up can lead to serious repercussions.
Habitual mistakes may lead to remedial training.
Mistakes are more likely when tired or in high-pressure situations, emphasizing the need for careful documentation.
The medical director's role is mentioned in relation to documentation and error handling.
Accurate documentation of simulated patient encounters is emphasized.
The importance of complete and accurate documentation is stressed.

Most systems are now electronic, using devices like iPads for real-time documentation and cloud uploading.
Handwritten reports are becoming less common.

Different titles for reports: run report, patient care report, pre-hospital care report.
Patient care report and pre-hospital care report are essentially the same.
A run report is a sheet used to keep track of essential information during a call.

Verbal report given to someone of equal or higher medical authority.
PCR must be 100% complete before leaving the hospital, except in specific circumstances (district is running low on ambulances).
In such cases, a run report copy can be left with the nurse, but the PCR must be completed promptly.
Completing the PCR at the hospital is the best practice to avoid forgetting critical information.
It helps prevent legal issues years later.
Addendums can be added to reports after submission to correct omissions.

How to handle situations where information for PCR is missing (e.g., patient unable to communicate).
Document what you have and why you don't have certain information.
Searching the patient for ID is sometimes necessary but should involve law enforcement.

The narrative should be objective (black and white, no opinions).
It can contain subjective findings (e.g., patient's feelings).
Subjective findings: descriptions of patient's feelings
Example: Documenting a patient's pain level, even if it seems inconsistent with their presentation.

Key times (911 call, dispatch, arrival, transport initiation, arrival at destination, verbal report).
Patient's chief complaint, weight, vital signs, age, gender, race.
The narrative should tell a brief story, including both objective (pulse rate, breathing rate, blood pressure) and subjective (patient-described symptoms) information.
Example: Documenting a patient's reported pain level and their ability to ambulate.

In electronic reports, corrections are made via an "addendum" or similar feature.
Never completely cover incorrect information, as it may appear like an attempt to hide something.

The quality of documentation reflects the quality of care provided.
Lawyers will scrutinize documentation for errors and inconsistencies to undermine credibility.
Poor grammar, incomplete sentences, and incorrect punctuation can negatively impact perceptions of competence.

Document everything the patient says.
Documentation can be data to improve care.
Example: A case where a granddaughter, who was an EMT, filed a complaint because proper C-spine precautions were not taken

Essential elements to document for refusal of care:
- Verbal refusal.
- Competency (oriented times four).
- Informed consent (risks of refusing care).
- Advice to call 911 if anything changes.

Smartphones and applications allow for quick documentation.
Reviewing and signing reports, even if not the primary caregiver, signifies agreement with the documented events and assumes liability.