DOCUMENTATIONDOCUMENTATION

Finishing the JobFinishing the Job

“ “ I first saw the slow-moving, sad I first saw the slow-moving, sad faced old gentleman when he faced old gentleman when he bounced off the hood of my car”bounced off the hood of my car”

WHY?WHY?

WHY?WHY?

Continuity of CareContinuity of Care Quality ImprovementQuality Improvement BillingBilling Data CollectionData Collection Legal ProtectionLegal Protection

‘‘Coming home, I drove my car into Coming home, I drove my car into the wrong house and collided with a the wrong house and collided with a tree I don’t have.’tree I don’t have.’

WHAT?WHAT?

According to Montana Licensing Rules:According to Montana Licensing Rules: ID of EMS providerID of EMS provider Date of callDate of call Pt’s. name and addressPt’s. name and address Type of runType of run ID of all providers, riders, trainees, or ID of all providers, riders, trainees, or

service personnel officially responding to service personnel officially responding to callcall

AND….AND….

Time:Time: Dispatch is notifiedDispatch is notified EMS is notifiedEMS is notified EMS enrouteEMS enroute Arrival on sceneArrival on scene Left scene or turned over care Left scene or turned over care Arrival at receiving hospitalArrival at receiving hospital

AND….AND….

Utilization of online medical controlUtilization of online medical control History of pt’s. illness/injury, History of pt’s. illness/injury,

including physical exam findingsincluding physical exam findings Treatment provided or offeredTreatment provided or offered VS including time takenVS including time taken Destination of patientDestination of patient

““In my attempt to kill a fly, I drove In my attempt to kill a fly, I drove into a telephone pole.”into a telephone pole.”

WHEN??WHEN??

As soon as possible upon arrival at As soon as possible upon arrival at receiving facility, but no more than receiving facility, but no more than 48 hr. after end of pt. transport.48 hr. after end of pt. transport.

Receiving hospital must receive copy Receiving hospital must receive copy of PCR of PCR

WHO?WHO?

Primary care provider should write the Primary care provider should write the narrative and pt. care findings.narrative and pt. care findings.

All providers should have input. All providers should have input.

“ “ I pulled away from the side of the I pulled away from the side of the road, glanced at my mother-in-law in road, glanced at my mother-in-law in the other seat and headed over the the other seat and headed over the embankment.” embankment.”

NarrativeNarrative

Formats:Formats: ChronologicalChronological Anatomical systemsAnatomical systems SoapSoap

Subjective Subjective ((SStuff that people told you)tuff that people told you) Objective Objective ((OObservations)bservations) Assessment Assessment ((AActual problem)ctual problem) PlanPlan ( (PPlan for treatment)lan for treatment)

What type is this?What type is this?

Dispatched by 911 to Penderson oil well site for a 29-year Dispatched by 911 to Penderson oil well site for a 29-year old male pt. involved in industrial accident. Upon arrival, I old male pt. involved in industrial accident. Upon arrival, I found pt. lying in lateral recumbent position, alert & found pt. lying in lateral recumbent position, alert & oriented, airway patent, breathing non-labored, circulation oriented, airway patent, breathing non-labored, circulation adequate, pupils ERL, GCS 15. Pt. stated he fell from adequate, pupils ERL, GCS 15. Pt. stated he fell from standing position, landing on right lower lumbar region of standing position, landing on right lower lumbar region of back. Pt. complained of pain in that area (9 out of 10) back. Pt. complained of pain in that area (9 out of 10) rendering him unable to walk. I assessed the back and rendering him unable to walk. I assessed the back and extremities—CMS intact X 4, noted redness and swelling on extremities—CMS intact X 4, noted redness and swelling on back on lower right side. Immobilized pt. to long spine back on lower right side. Immobilized pt. to long spine board, obtained baseline vital signs (listed above), and board, obtained baseline vital signs (listed above), and initiated transportation. I continued to monitor the pt. initiated transportation. I continued to monitor the pt. enroute, and his condition was unchanged. Arrived at SMH enroute, and his condition was unchanged. Arrived at SMH ER, transferred care to RN Lisa Fawcett.ER, transferred care to RN Lisa Fawcett.

Chris’ FormatChris’ Format

Document:Document: What you saw.What you saw. What you did.What you did. What happened after you did it.What happened after you did it.

If you write at allIf you write at all

You must write it allYou must write it all

Because the law presumesBecause the law presumes

You wrote it all,You wrote it all,

If and when you write at all.If and when you write at all.

And….And….

Treatment should reflect Treatment should reflect assessment.assessment.

Document need for emergency Document need for emergency transport.transport.

No-NosNo-Nos

Do not use unapproved abbreviations.Do not use unapproved abbreviations. Do not inject opinions.Do not inject opinions. Watch punctuation.Watch punctuation. Use appropriate, properly spelled Use appropriate, properly spelled

medical terms or don’t use them at all.medical terms or don’t use them at all. Don’t use medical slang.Don’t use medical slang. Don’t scribble out or write over Don’t scribble out or write over

mistakes.mistakes.

((called out for male patient with shortness called out for male patient with shortness of breath)of breath)

Arrived on scene Pt. was sitting in recliner Arrived on scene Pt. was sitting in recliner in living room and in back pain! Pt’s. O2 in living room and in back pain! Pt’s. O2 sat was good—vitals were good, (sat was good—vitals were good, (vitals: vitals: pulse 80-100, resp. 20, BP 128/71, Pox pulse 80-100, resp. 20, BP 128/71, Pox 96%) 96%) Pt. stated he has had back pain for Pt. stated he has had back pain for several years. Pt. stated he had no other several years. Pt. stated he had no other medical problems, Pt’s meds were medical problems, Pt’s meds were gathered and brought with. Pt. was gathered and brought with. Pt. was assisted to stair chair then to stretcher. assisted to stair chair then to stretcher. Pt. was a little agitated.Pt. was a little agitated.

Pt. lying in bed—cool, clammy, slow to respond. Pt. lying in bed—cool, clammy, slow to respond. Opened eyes when talked to—unable to talk. Opened eyes when talked to—unable to talk. Caregivers stated they found her this way on room Caregivers stated they found her this way on room check. Pt. incontinent of urine/stool. Skin cool, check. Pt. incontinent of urine/stool. Skin cool, clammy Pt. naked. Pt given 1 tube glutose—able clammy Pt. naked. Pt given 1 tube glutose—able to swallow. Pulse weak, thready. Pt. attempted to to swallow. Pulse weak, thready. Pt. attempted to speak following glutose-could say words but unable speak following glutose-could say words but unable to understand. Pt. lifted onto cot with 5 people. to understand. Pt. lifted onto cot with 5 people. Pox improved with addition of O2—NRB 15L. Pox improved with addition of O2—NRB 15L. Caregivers stated pt was fine last night. No known Caregivers stated pt was fine last night. No known illness—ate a good supper. Caregiver also stated illness—ate a good supper. Caregiver also stated pt was ok at 1230—Enroute—pt. started vomiting—pt was ok at 1230—Enroute—pt. started vomiting—clear yellow emesis—suction used to clear airway. clear yellow emesis—suction used to clear airway. Medication/allergy list given to Nurse Medication/allergy list given to Nurse (name). (name). Pt. Pt. not normally on home O2 .not normally on home O2 .

My favorite…My favorite…

12/03/83 dispatch time 090312/03/83 dispatch time 0903 35-y.o. male35-y.o. male VS: VS: P strong/reg equal R 14P strong/reg equal R 14 Suspected injury/illness: Suspected injury/illness: snowmobile acc. poss fx snowmobile acc. poss fx

forearms & Lt ankle, lac. Rt side cheekforearms & Lt ankle, lac. Rt side cheek Notes/medical history: Notes/medical history: NPH, NKA, NKM, splinted NPH, NKA, NKM, splinted

both forearms & wrapped in blankets, placed on both forearms & wrapped in blankets, placed on scoopscoop

Emergency care rendered: Neck/spine Emergency care rendered: Neck/spine immobilization immobilization (per scoop stretcher)(per scoop stretcher) box checked box checked on scene but not enrouteon scene but not enroute

““an invisible car came out of an invisible car came out of nowhere, struck my vehicle and nowhere, struck my vehicle and vanished.”vanished.”

Can we change the chart?Can we change the chart?

Written policy:Written policy: Only the original author should make Only the original author should make

modifications.modifications. All entries made after the PCR is initially All entries made after the PCR is initially

completed should be signed and dated. completed should be signed and dated. Addendums should be cross-referenced to Addendums should be cross-referenced to

original PCRoriginal PCR All who signed the PCR should be notified of All who signed the PCR should be notified of

changes/addendums.changes/addendums.

(0625)(0625) Pt. slumped on floor against bed on EMS arrival-in sitting Pt. slumped on floor against bed on EMS arrival-in sitting

position with positional airway. Snoring respirations-thick position with positional airway. Snoring respirations-thick secretions noted on face et beard. Pt. initially unresponsive. secretions noted on face et beard. Pt. initially unresponsive. Family stated pt. had a seizure lasting 1-2 minutes prior to Family stated pt. had a seizure lasting 1-2 minutes prior to calling EMS. Airway positioned via jaw thrust. Oxygen calling EMS. Airway positioned via jaw thrust. Oxygen applied via NRB @ 15 LPM. Pt. became combative, flinging applied via NRB @ 15 LPM. Pt. became combative, flinging arms, et struggling against responders. Unable to assess arms, et struggling against responders. Unable to assess vitals due to pt. response. Difficult extrication due to large vitals due to pt. response. Difficult extrication due to large size of pt, small quarters. Pt. placed on backboard, size of pt, small quarters. Pt. placed on backboard, backboard slid out of bedroom to cot. After pt. loaded to backboard slid out of bedroom to cot. After pt. loaded to ambulance (0648) he had another seizure lasting 1 ½ ambulance (0648) he had another seizure lasting 1 ½ minutes-head movement noted to L. Pupils unresponsive. minutes-head movement noted to L. Pupils unresponsive. Assisted with airway management in ICU. Pt’s arms were Assisted with airway management in ICU. Pt’s arms were restrained with Kurlex bandage to protect patient during restrained with Kurlex bandage to protect patient during move.move.

(See addendum) (See addendum)

Addendum:Addendum: 12/29/07 PCR # 3165712/29/07 PCR # 31657 Pt. had c/o severe headache for past 2 Pt. had c/o severe headache for past 2

days—per wife.days—per wife. Large amt. of phlegm/mucous noted in Large amt. of phlegm/mucous noted in

waste can & on floor.waste can & on floor. Pt. incontinent of urine.Pt. incontinent of urine. Sheriff (Sheriff (namename) on scene to assist.) on scene to assist. Signed and dated by all respondersSigned and dated by all responders..

RefusalsRefusalsAA33EE33PP33

AAssessssess AAdvisedvise AAvoidvoid EEnsurensure EExplainxplain

EExploitxploit PPersistersist PProtocolrotocol PProtectrotect

Law enforcement on scene on our arrival. Pt. had Law enforcement on scene on our arrival. Pt. had been unresponsive prior to EMS arrival per Sgt. been unresponsive prior to EMS arrival per Sgt. Ulrickson. On EMS arrival Pt. was awake, agitated Ulrickson. On EMS arrival Pt. was awake, agitated and refused assessment, treatment or transport. and refused assessment, treatment or transport. No injuries noted on visual assessment. Pt. No injuries noted on visual assessment. Pt. denied injury. Stated he laid down on sidewalk to denied injury. Stated he laid down on sidewalk to ‘take a power nap’. Pt. able to move all ‘take a power nap’. Pt. able to move all extremities equally—insisted on standing up. extremities equally—insisted on standing up. Gait unsteady. Alert to time, place, date. Refusal Gait unsteady. Alert to time, place, date. Refusal signed. Pt. advised he could call EMS or seek signed. Pt. advised he could call EMS or seek further medical assistance at any time. Pt. further medical assistance at any time. Pt. escorted home by friends. escorted home by friends.

REMEMBER:REMEMBER:

If it wasn’t written down, you If it wasn’t written down, you didn’t do it, see it, treat it or didn’t do it, see it, treat it or prepare for it.prepare for it.

Documentation ScenariosDocumentation Scenarios

EMT-B CourseEMT-B Course

Me Neither…….Me Neither…….

2325 dispatched to possible diabetic 2325 dispatched to possible diabetic emergencyemergency

51 y.o. male with history of diabetes 51 y.o. male with history of diabetes

Plan of ActionPlan of Action

Assess for responsivenessAssess for responsiveness Complete initial assessmentComplete initial assessment Check blood sugarCheck blood sugar If conscious and symptomatic, If conscious and symptomatic,

administer glutoseadminister glutose Re-assessRe-assess Transport?Transport?

On-Scene @ 2327On-Scene @ 2327

Wife meets EMS @ door.Wife meets EMS @ door. States husband is seizingStates husband is seizing

in bedroomin bedroom

General Impression General Impression Wife states she was flushing Wife states she was flushing

husband.husband.

“Looks like Billy clogged up the toilet again.”

General Impression: General Impression: Oh, Fudge!!Oh, Fudge!!

Noted pt. in full seizureNoted pt. in full seizure Connected to a strange Connected to a strange

machinemachine

Facts:Facts:

Seizure was witnessed by EMS for approx. 8 minutes. Seizure was witnessed by EMS for approx. 8 minutes. Blood sugar was 33 about ½ hr. ago. Blood sugar was 33 about ½ hr. ago. Pt. was on home dialysis.Pt. was on home dialysis. Pt. woke up after seizure stopped.Pt. woke up after seizure stopped. Pt. is on home dialysis.Pt. is on home dialysis. Oxygen was applied.Oxygen was applied. Pt. was aware of his environment.Pt. was aware of his environment. Vital signs were not taken due to seizure activity.Vital signs were not taken due to seizure activity. Airway was positioned manually.Airway was positioned manually. Dialysis tubing was clamped and disconnected from pt.’s Dialysis tubing was clamped and disconnected from pt.’s

port.port. Respirations were snoring.Respirations were snoring. Seizure stopped @ 2334.Seizure stopped @ 2334. Oxygen was applied at 15 l./min per non-rebreather mask.Oxygen was applied at 15 l./min per non-rebreather mask.

Outcome:Outcome: Left scene 2336Left scene 2336 Arrived @ hospital @ 2337Arrived @ hospital @ 2337 Pt. ambulating in ER by 0015Pt. ambulating in ER by 0015 Pt. shared that he has a manual Pt. shared that he has a manual

for dialysis machinefor dialysis machine Later had to have shunt Later had to have shunt

replacedreplaced Pt. received kidney transplant Pt. received kidney transplant

last winter and is doing welllast winter and is doing well

I’ve Fallen and I Can’t Get I’ve Fallen and I Can’t Get Up…..Up…..

2212 Dispatched to local residence2212 Dispatched to local residence 62 y.o. male pt. has fallen and 62 y.o. male pt. has fallen and

unable to get up—no injuriesunable to get up—no injuries

General impression:General impression:

Arrive on scene @ 2219Arrive on scene @ 2219 Morbidly obese pt. below knee amputationMorbidly obese pt. below knee amputation

—right leg. —right leg. Hx. DiabetesHx. Diabetes GCS 15—alert and orientedGCS 15—alert and oriented Denied injury or painDenied injury or pain Abrasions noted to both kneesAbrasions noted to both knees

AssessmentAssessment

Pt. stated he had been having diarrhea Pt. stated he had been having diarrhea since this morningsince this morning

Had fallen while enroute to bathroomHad fallen while enroute to bathroom Wife and 2 neighbors unable to assist pt. Wife and 2 neighbors unable to assist pt.

from floorfrom floor Trauma assessment done with no injury Trauma assessment done with no injury

foundfound

Moving right along….Moving right along….

Lifted pt. to wheelchair with assist of 3 Lifted pt. to wheelchair with assist of 3 EMS, wife, and 2 neighborsEMS, wife, and 2 neighbors

Used the megamover to lift pt.Used the megamover to lift pt. Pt. denied need for transportPt. denied need for transport Cot returned to rigCot returned to rig EMS cleansed knee abrasionsEMS cleansed knee abrasions Initiated VS—P. 54 Sats 94% Resp. 22 Initiated VS—P. 54 Sats 94% Resp. 22

labored, Blood sugar 332labored, Blood sugar 332

And then…..@ 2232And then…..@ 2232

Snoring respirations and decreased Snoring respirations and decreased LOC—GCS 3LOC—GCS 3

No palpable pulseNo palpable pulse

TreatmentTreatment

CPR initiatedCPR initiated Pt. moved to floorPt. moved to floor Cot, Code Kit and rest of team retrievedCot, Code Kit and rest of team retrieved AED applied, shock X 1 @ 2333AED applied, shock X 1 @ 2333 Assisted ventilation utilizing bag-valve Assisted ventilation utilizing bag-valve

mask and oxygen.mask and oxygen. Oral airway inserted.Oral airway inserted. Transport delayed while waiting for Transport delayed while waiting for

requested assistance to move pt.requested assistance to move pt.

Response:Response:

Left scene @ 2243Left scene @ 2243 CPR continued enrouteCPR continued enroute @ hospital @ 2244—cardiac @ hospital @ 2244—cardiac

monitor shows V Tachmonitor shows V Tach

OutcomeOutcome

Pt. became responsive in CCUPt. became responsive in CCU Had been intubated, but was able to Had been intubated, but was able to

communicatecommunicate Flown to BismarckFlown to Bismarck Died 2 weeks later from repeat MIDied 2 weeks later from repeat MI

Case of the Wooden SpoonCase of the Wooden Spoon

0200 dispatched to rural area for a 0200 dispatched to rural area for a male pt. Possible strokemale pt. Possible stroke

First ImpressionFirst Impression Wife met us at the door with a Wife met us at the door with a

large wooden spoon in her large wooden spoon in her hand.hand.

?????

General Impression:General Impression:

Pt. sitting in chair in bedroom, Pt. sitting in chair in bedroom, clutching left shoulderclutching left shoulder

Color gray, skin diaphoreticColor gray, skin diaphoretic c/o left shoulder pain/weakness c/o left shoulder pain/weakness

AssessmentAssessment

Oriented but slow to respond to questions Oriented but slow to respond to questions Airway clearAirway clear Breathing slightly rapidBreathing slightly rapid Unable to palpate radial pulseUnable to palpate radial pulse Carotid pulse weakCarotid pulse weak Unable to obtain BPUnable to obtain BP

TreatmentTreatment

High flow oxygenHigh flow oxygen Position of comfortPosition of comfort TransportTransport

EnrouteEnroute

Rookie EMT asks stupid questionRookie EMT asks stupid question Pt. answered: “fell off my horse Pt. answered: “fell off my horse

yesterday”yesterday”

Outcome:Outcome:

Pt. was in hypovolemic shock due Pt. was in hypovolemic shock due to ????? to ?????

ruptured spleenruptured spleen

Lessons Learned:Lessons Learned:

Spleen injury refers to left shoulderSpleen injury refers to left shoulder There is no such thing as a stupid There is no such thing as a stupid

question.question.

Side Note:Side Note:

The rookie EMT is now The rookie EMT is now an ER physician in an ER physician in MinneapolisMinneapolis

Case Study # 3Case Study # 3

0909 dispatched to local drug store 0909 dispatched to local drug store for ‘elderly male who has passed out’for ‘elderly male who has passed out’

0917 Arrived on-scene0917 Arrived on-scene

Scene size-upScene size-up

Elderly male sitting in chair at check-out Elderly male sitting in chair at check-out countercounter

Pharmacist diverted first EMT to give an Pharmacist diverted first EMT to give an account of events leading up to activating account of events leading up to activating EMSEMS ‘‘Slim’ had come in to get his hearing aid batteries Slim’ had come in to get his hearing aid batteries

replaced and wanted his NTG Rx refilledreplaced and wanted his NTG Rx refilled Slim was standing out check-out and bent over, Slim was standing out check-out and bent over,

laying his head on the counter—did not totally laying his head on the counter—did not totally lose consciousness or fall.lose consciousness or fall.

Slim stated that all he could see was a ‘white wall’ Slim stated that all he could see was a ‘white wall’

Size-up/Initial AssessmentSize-up/Initial Assessment

Pharmacist expressed his concern that Slim Pharmacist expressed his concern that Slim was not capable of driving himself at this was not capable of driving himself at this point.point.

Slim stated the following: Slim stated the following: He did not need an ambulanceHe did not need an ambulance He did not call the ambulanceHe did not call the ambulance He was not going to pay for the ambulanceHe was not going to pay for the ambulance Pharmacist would not fill his ‘dynamite’ pills until he Pharmacist would not fill his ‘dynamite’ pills until he

contacted Slim’s providercontacted Slim’s provider

Assessment Findings:Assessment Findings:

78 y.o. male78 y.o. male Alert/oriented to time, place, eventAlert/oriented to time, place, event Color pale/ skin diaphoreticColor pale/ skin diaphoretic Radial pulse 64/ regular/weakRadial pulse 64/ regular/weak BP 72/40BP 72/40 Unable to obtain Oxygen sat level (hands Unable to obtain Oxygen sat level (hands

felt cold) felt cold) Hx: CAD, Arteriosclerosis, emphysema, 2 Hx: CAD, Arteriosclerosis, emphysema, 2

coronary stintscoronary stints

Further assessment Further assessment findings:findings:

Pt. is severely hearing impairedPt. is severely hearing impaired Walks with a cane s/p 2 hip Walks with a cane s/p 2 hip

replacementsreplacements Wife is in hospitalWife is in hospital When questioned about medications When questioned about medications

pt. stated “heart meds—Dr. knows pt. stated “heart meds—Dr. knows what I take”what I take”

22ndnd pulse check: 88/irregular pulse check: 88/irregular

Responder Suspicions??Responder Suspicions??

Dehydrated?Dehydrated? Low blood sugar?Low blood sugar? Stress?Stress? Hypotension due to???Hypotension due to???

Next question……Next question……

Did you take your meds?Did you take your meds?

Did you take a NTG?Did you take a NTG?

Were you having chest pain?Were you having chest pain?

Challenges:Challenges:

Communication due to hearing lossCommunication due to hearing loss Poor historianPoor historian Refusal for transportRefusal for transport My DadMy Dad

Outcome:Outcome:

0929 Pt. was transported to hospital 0929 Pt. was transported to hospital per daughter’s insistenceper daughter’s insistence

Pt. was given IV fluids and instructed Pt. was given IV fluids and instructed by Provider to take NTG by Provider to take NTG onlyonly for chest for chest painpain

Pt. admitted to hospital over night for Pt. admitted to hospital over night for evaluationevaluation

Daughter still not forgiven.Daughter still not forgiven.

Ponderings??Ponderings??