Guide to Documenting with ERS

This class covers the overall objectives and instructions for documenting EMS and Fire Events.Kennewick Fire Department Documentation Program

A Message From Deputy Leonard

OBJECTIVESImprove the overall documentation & review practices of the Kennewick Fire Department.Save time and resources in accomplishing overall documentation efforts.Get away from Living the call twiceInitial, Review, Quality Assurance, Finance, AdministrativeProvide the necessary information to not only describe our actions, but enable the department to leverage our data for justifying our current actions and forecasting ours future needs.Current Life of an EMS PCR Fire Data CollectionWIMSIS EMS Data Collection WACARES Justification Validation Protection Billing / Finance Justification Administrative Budgets WIMSISCALL123456Flow Chart / ER / PCR / Run Review / QA / Finance / AdminThe reality is, if we are not able to justify why we did or didnt do something, we cant get paid, and we cant live up to the expectations of city government, the MPD, or the citizens we serve.4Current Life of an EMS PCR Fire Data CollectionWIMSIS EMS Data Collection WACARES Justification Validation Protection Billing / Finance Justification Administrative Budgets WIMSISCALLThe reality is, if we are not able to justify why we did or didnt do something, we cant get paid, and we cant live up to the expectations of city government, the MPD, or the citizens we serve.5OBJECTIVES ContinuedEnsure every member of the department is documenting in a consistent and appropriate manner.Improve the efficiency of our review processes.Ensuring consistency between all of our EMS and Fire Records.4 people should not have to look at a single record to validate that everything is correct.

If our Schedule II drug log does not add up to our EMS documentation, we have an issue. 6CLASS SECTIONSDocumentation SOGDocumenting EMS Reports in ERS.Adjunct documentation practicesECG StripsWaiver formsRefusalsPersonal Recollection RecordsWhat does the future hold?PPACA [Obama Care]?Increased efficiency through tablets & wireless communication with the Zoll & ER.An on-line QA Process giving you early feedback.

8Good Documentation inthe Kennewick Fire Department!We have good documentation. Singley & the MVA Accident. Huck and great narrative re a fall patient. Jorgensen, Howrey, Anema, Stratford, Williamson, Crowley all do some great documentation. 9Records & ReportsIncident Reporting / Fire & EMSRevised June 20, 2013SOG 1 VII - 1SOG ParticularsPurposeA procedure for all staff to follow when documenting.ScopeApplies to all KFD personnel & shall be used for all forms of documentation.ResponsibilitiesThe Chief or designee is responsible for ensuring compliance.

Fire Reporting

Basic Concepts Identified in SOGReport shall be completed for all assigned responses of Fire or EMS apparatus.Each unit that responds shall complete a report including times, delays, personnel, & a S.A.C. narrative.SituationActionsConclusionsKFD is going to start using the SAC methodology for documenting events at a fire, rescue, or haz mat incident.12EMS Reporting

All EMS Reports shall be filled out by the person in charge of patient care in accordance with WAC 246-976-330Dates & TimesMedicare FieldsNarrative(s)AttachmentsGeneral Reporting Parts & PiecesApparatus TimesEach unit is responsible for their own times, delays, discrepancies, etc.If a delay of total travel time, exceeds 8 minutes, an explanation of the delay shall be documented in the narrative.Auto & Mutual Aid responses into the COK will require all times to be entered.Auto & Mutual Aid responses out of the COK require only KFD times to be entered.Fire NarrativesTypically speaking all narrative (except EMS) shall answer the questions of Who, What, When, and Where.Fire narratives shall additionally follow the SAC format.SituationUpon arrival, periodic updates as incident progresses, as well as tasks are completed, changed or added.ActionsActions taken by the unit, crew, division, etc.ConclusionsResults of the actions taken by the unit, crew, division, etc.S.A.C Example Car FireS:EN1813 arrived to 4 door passenger vehicle on residential street, with flames from engine & passenger compartment. Owner standing 50 feet away with spent extinguisher. No exposures or other hazards noted in size-up.A:Fire attack with 100 bumper pre-connect with foam, and all firefighters in full PPE. Forced hood. Doors opened without force. PD on scene performing traffic control and calling for wrecker. C:Fire extinguished with tank water. No hazards leaking from vehicle after extinguishment. After ensuring fire was out, engine placed back in service. Cleared scene AV.S.A.C Example Structure FireS:EN1811 arrived at the scene and staged apparatus at 9th & Vancouver, moved personnel and tools up to scene. Assigned by IC to back-up EN1814 who was interior from the A Side, making initial attack on fire currently located in CD corner. A:Made entry with tools & 1 3/4 line and 3 personnel on air through A Side. Performed back-up without incident until EN1814 crew exited structure due to low air alarms. C:IC advised EN1811 crew to move up to Interior Attack. Captain 61 conducted face to face with EN1814 as they exited structure. IC advised EN1813 to move up to back-up. EN1814 resumed fire attack at CD corner.Who would write a S.A.C. Narrative?Incident CommanderDivision SupervisorGroup SupervisorCaptain Individual who witnessed or performed a specific task?

Fire Investigation NarrativesThe fire investigation narrative shall comply with NFPA 921. It shall communicate the observations, analyses, and conclusions of the investigation.FormatDescriptive InformationPertinent FactsOpinions & ConclusionsSee SOG D.3 for more detail.

PCR / MIR NarrativesPatient Care Reports shall be written in the SOAP Format using proper English, correct spelling, capitalization, and punctuation.Any abbreviations used MUST be identified in the official Benton Franklin County EMS Protocol list.Certain types of events require specific data to be obtained, even if a patient care report is not being completed. (For Example:Motor Vehicle AccidentsAssist Invalid CallsNo Transport Calls (NOT Patient Refusals)Supplemental NarrativesAddendumsMore Later!Completion of ReportsAll units responding to an incident shall complete a narrative.The officer completing the report may request individuals to complete individual narratives.EMS reports must be completed within 6 hours.

FUTURE?A timer that notifies the shift commander a unit has not submitted a report. Allows for BC to determine if unit needs to be OOS to complete documentation.21Completion of ReportsAll other documentation should be completed prior to the end of shift.The Company Officer or Incident Commander is ultimately responsible for the content and completion of the report.

Medical Incident Documents & PhotographsECG Strips taped to a separate piece of paper.Transmitted 12 LeadsFacility Face sheetsMedication ListsABN, PCS & Waiver FormsRefusal FormsFlow Sheets?If the document is scanned and uploaded into the records management system, it MUST be included in the hard copies forwarded to finance.

Consider scanning your flow sheet in with patient documentation. This will help you to recall information later if you have to reconstruct or provide additional information that is found missing after review.23Medical Incident Documents & Photographs

Pictures taken at a scene should also be uploaded into ERS.A department wide Photo and Publication SOG is needed to clarify dos and don'ts. For now ask yourself Would I want this on KEPR at 6 PM?Twitter, Facebook, scene photos and more need to be addressed comprehensively.24Quality AssuranceAll documentation will be reviewed by the following shift.Discrepancies in the Basic / Key Fields may be corrected by the reviewer.Discrepancies in the EMS or Narrative sections of the report MUST be corrected by the author. Upon finding a discrepancy, the reviewer will:Initiate an email to the individual with a cc: copy to the persons immediate supervisor.Within the email, provide a list of the issues and needs for the documentation to be considered complete.The author will remedy the issues ASAP!The individuals supervisor will complete the document as reviewed.More to follow later in the class.25Release of ReportsCopies of fire incident reports may be obtained from the Fire Administration Center M-F 8:00 AM 5:00 PM.509-737-0911Individuals requesting EMS reports must obtain them through the cities ambulance billing department.509-585-4379

Key FieldsNFIRS 5.0WACARESMedicare & Medicaid FieldsPPACASome of these fields are consistent and firm. Others though may change over time, especially with PPACA / Obama Care.

While we dont know all that Obama Care will bring, we do know this, it will require excellent documentation to prove why we did what we did, and why we did it.27Documents Left at the ERWAC 246-976-330 requires EMS to leave the following at the ER at the TIME of Patient Transfer:Date & Time of emergencyTime of symptom onsetVital Signs, including serial vitals if applicablePatient Assessment Findings, to include ECG strips.Procedures & Therapies provided by EMS personnel in the field.Any changes in patient condition while in the care of EMS personnel.Mechanism of injury or type of illness.

Significant Event NotificationsWhen out of the ordinary or big events happen, let your immediate supervisor know.Incidents occurring on City property, or involving a KFD or City Employee.Incidents posing a potential vulnerability to the City or employee.Incidents involving large dollar values, fatalities, or of public concern.Situations which will require the closure of a business or residence by the City or fire department.Other unusual or potential news worthy events.Power, radio, computer, and other infrastructure outages or issues.Complaints from the political figures, community reps, or dignataries.

Documenting Medication Errors6 Easy StepsCorrect the issue if possible. (Narcan for Morphine OD.)Immediately notify the ER Physician directly.Document the error completely in the PCR Narrative.Notify your immediate supervisor and complete the Medication Error Form in ERS.Notify the EMS Officer, to include event number and any other additional circumstances related to the error.Submit a performance improvement plan to your supervisor, with a copy to the EMS Officer, identifying steps that will be taken in the future to avoid such errors in the future.Ensures patient needs are met.Lessons are learned and future issues will not occur.30Schedule II Drug Logs & AuditsComplete the drug log daily per the SOG.Ensure that any medications given during the course of treatment are documented similarly in both the EMS documentation and the drug log.Notify your immediate supervisor any time you notice a significant error or discrepancy in the log.Follow the instructions in the drug log audit form and SOG.Schedule II Drug Logs & AuditsEvent can be an administration or adding or removing meds from the box.32Lets Take a Break!Guide to EMS & Fire Documentation within ERSThis document shall be used to provide instruction and guidance on daily EMS and Fire Documentation in ERS, as well as a guide for call review.

Basic Info 1

Using the drop down, this field identifies the Station Area the event took place in, NOT the station who responded to the event.The incident number should always be 5 digits, starting with a 0.Basic Info 1

Ensure the Incident Type does NOT end in 0.

Try to get the best description for the event.Basic Info 1

It is important to ensure this field is completed when, providing or receiving mutual or auto aid. (See next page.)When building a report, ensure the F Number is present.Auto vs. Mutual AidAuto-Aide AgreementsESZ 637 in Kennewick with RFD Station 72. BCFD #1 ESZs in 110 & 120 areas, when receiving any medical response from KFD.BCFD #1 ESZ 131 and 132 along the northern boarder of Kennewick.Mutual Aid AgreementsAny time KFD provides or receives aid from another agency, outside of the parameters listed above.BASIC 2

The PCR box should be used for ALL patients who receive an Assessment, regardless of need for treatment or transport. See SOG 1-VII-1 (Revised 2013.)

BASIC 2

Information about People Involved should be used for:

Parents of minor patients Persons who do not require a PCR, such as a person involved in an accident, but not requesting an Assessment. Reporting parties or witnesses Responsible parties at a scene of a fire or alarmBasic 3

Ensure addresses are in ALL CAPS.

Special attention should be paid to this line when the event is in Richland, Pasco or Finley, as these events may not have been auto-populated by CAD.Ensure the zone is accurate. This is automatically filled by CAD based on the ESZ the address is in.

If you are building the report, look for the ESZ on the rip-n-run or in I-Netviewer to identify this number.41Basic 3

Use the List to best identify the address property.

NOTE: There are only three 311s in the C.O.K. Most retirement homes are 459s (Residential Board and Care.)

See following slide.Ensure addresses are in ALL CAPS, even cross streets or directions.

42311s vs 459sNursing Homes (311)Calloway GardensLife Care of KennewickCanyon Lakes RestorativeResidential Board/Care (459)Royal ColumbianCanyon LakesPark View EstatesCharbonneauMost small elder care facilities

Basic 4

Look at the times for consistency and appropriateness. Anything with delays greater than 8:00 minutes should have an explanation in the narrative.

Basic 4Remember to check the response mode even if you check mark the box, This apparatus was cancelled.

Basic 5Do your best to get this code as close to the most appropriate field assessment or disposition as possible.

Dont forget you have options like; Sick Person if nothing else seams to fit.

Basic 5Ensure at least 1 Primary Action is taken.

32 = BLS (This even includes IVs and ECGs)

33 = ALS (Medication administration & advanced airway or CPAP)

34 = Transport EMSSection

For ANY PATIENT who has received an assessment.Use this section for each individual patient. Multiple patients should not be entered in one PCR.Questionnaire

Ensure this field is correct. Options include:

Transport by EMS Transport by POV Patient Refused Care Treated and Released Dead at the SceneQuestionnaire

Select all of the appropriate fields. For a patient who is Transported; a minimum of Transport and Billing MUST be checked if patient is transported.

*SEE STARRED AREAS*Questionnaire

In the case of a cardiac arrest, it is very important to ensure the Cardiac Arrest box is clicked.

Depending on transportation, determines if Billing and Transport is checked.Patient Information

Provide as much information about the patient as possible.

SSN are not needed.

Minimum Information Needed:

Name (No Nicknames) Address of individual not necessarily the event. Phone number Gender Weight Race DOB converted to AgeNames and Addresses in ALL CAPS & No Punctuation!Billing

Billing fields MUST include:

Pick up location using the most appropriate code in the drop down.

Mileage must include 3 digits, even if the first one is 0, and out to the first decimal. NO rounded numbers.

The example to the left is exactly how it should be.Ensure Pickup Location correlates with event location. Patient Complaint

This should be in the patients words. If patient is unconscious or unable to speak, consider putting in Third party reports

Otherwise enter reason patient was unable to provide chief complaint.Patient Complaint

Utilize all of the information available to best choose the appropriate drop downs.

For Example:If the Primary Impression is respiratory in nature, more times than not the Complaint Anatomical Region would be Chest.

VitalsWhen possible, try to provide at least 2 sets of vital signs.

Vitals should be documented in this field at a minimum. VS in the narrative are extra.Billing CANNOT occur without at least one set of vital signs!Vitals

12Injury

This field shall be used for Major Traumas. Use this field to better document the location of injuries & trauma noted by you while you were with the patient.Cardiac

Use this field to best describe the events revolving around any confirmed cardiac arrest patient.

Again the more detail that can be provided, the better.Interventions

Ensure this box is checked, either while completing the report or during review.At a MINIMUM, the Primary Patient Caregiver MUST be identified.ALL ALS PROCEDURES AND MEDICATIONS MUST BE ENTERED INTO THIS FIELD. If they are not, the reviewer should reject the report.This page holds a lot of information that we use for anticipating supply needs, as well as helping us track certification pieces for intubations, IVs, etc. 60Destination

Destination should be identified in both this field and narrative.

Ensure you have selected the correct hospital / ER destination.

Narrative should be used to correlate destination fields.

Destination

Using the drop downs, (and the info on the following page), select the most appropriate information for this event.Reason for Choosing DestinationClosest FacilityTypically used when others dont applyDiversionHospital / ER diverts the patientLaw Enforcement ChoiceFor patients in custody but not driven by other protocol.Patient ChoiceWhen stable & protocol does not dictateFamily ChoiceWhen stable & protocol does not dictateProtocolCardiac, Stroke, Trauma, etc.On-line Medical Direction

When is KGH really Closer?KRMCKGHLMCK-FSERDeciding which is the most appropriate is only HALF the issue!We also need to document why you chose the location.

KRMC Cardiac triage tool, neuro capabilityKGH Pediatric trauma protocolLMC Patient choiceKFSER Patient choice, minor medical65Narrative

Narrative shall be completed in the SOAP format: Subjective (What you were told) Objective (What you saw) Assessment (Your diagnosis) Plan (What you did in chronological order)Signature MUST be the same as what is on your certification card, followed by your credential (EMT, AEMT, paramedic).Improving Our Subjective NarrativesA complete SAMPLEDSymptomsAllergiesMedicationsPrevious Medical HistoryLast Oral IntakeEvents Leading Up to NowDeniesIf picking a patient up from an ER for Transport to another facility Please provide why the patient is being transferred!

Improving Our Objective NarrativesPatient position & activity on arrivalGeneral appearance & level of consciousnessWeight, ethnicity, skin, etc.Exam FindingsHead to Toe, orBody Systems, orFocused exam findingsGadgetsECG, BG, SaO2, ETCO2, Vitals, etc.Improving Our AssessmentsBe Specific DO NOT use Rule OutWhat did you treat the patient for?Examples:Exacerbation of CHFSTEMILeft femur fracture secondary to MVCPenetrating trauma to left chestInsulin shockStroke

Improving Our Plan NarrativesWritten chronologicallyBSI, exam, VS, history, BG, IV 1000 NS via 18 ga @ R AC @ WO, 25 G D50W slow IVP, recheck BG 180 mg/dl, etc. etc. etc.Give justificationsC-Spine cleared per T4 ProtocolPt transported to KRMC per C9 ProtocolBe specific & give results100 mcg Fentanyl slow IV, Pt Pain down to 4/10,AddendumsWhen you have completed a report, date & time stamp it. Any change, clarification or addition after that MUST be done as an addendum.If you make ANY change to any part of the EMS section, make a note at the bottom of the narrative describing the change.QA Officers will also note date and time event was reviewed at bottom of narrative.Files

RULES for FILES:

All documentation attached to report MUST be scanned and uploaded, including ECGs.Complete the waiver before scanning and uploading.ECGs should be taped the back of the waiver or a blank sheet of paper, (not to the front of the report.)Do NOT throw away documentation that you have scanned and uploaded.Uploaded filed MUST be PDFs not JPEGs.Custom Fields

STEMI should be checked YES if you believe it was a STEMI, even if later determined not to be a STEMI.Custom Fields

Be as accurate as possible to identify this field.Custom Fields

Use this field to identify all traumas, regardless if it was a trauma system activation or not.Trauma Section

When completing the Trauma Section, identify all steps of the trauma system that were met by the patients initial presenting conditions.

Include in the criteria, if trauma system activation was requested in the field.