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Patient Care Documentation“A Proactive Approach”
- Richard W. Patrick, B.S., EMT-P/FF
- Steven A. Forry, EMT-P
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Objectives
State the importance and benefits of professional patient care documentation.
Understand the importance of following treatment protocols and standing orders.
Differentiate the criminal, civil, and ethical implications of patient care documentation.
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Objectives Con’t
Understand the responsibility to properly assess, treat, stabilize, transport, and document the care provided to their patient, as identified in their scope of practice and within their standard of care.
Develop a methodology for obtaining objective and subjective patient care information using open and closed ended questions.
State the differences in civil, criminal, and possibly punitive aspects of alleged malpractice.
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Objectives Con’t
Recognize the value of prospective, concurrent, and retrospective continuous quality improvement through positive rather than negative reinforcement and disciplinary action.
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Scenario #1
53 y/o male, c/o SOB PMH: CHF MEDS: Lasix Allergies: None Vital Signs:
– 162/88, P-112, R-38– 168/90, P-124, R-36
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Identifying the Problem
Coupled to the need for quality patient care is the need for appropriate and thorough documentation of your findings
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Identifying the Problem
“a properly completed PCR can prevent a prehospital care provider from being sued, or, in the event that an incident is litigated, can dramatically improve the providers chances of winning the lawsuit.”
- Richard A. Lazar, JD
- Robert J. Schappert III
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Identifying the Problem
“if the EMS training institutions have failed to adequately teach EMT students to document, they likely have also failed to establish standards for the profession of prehospital care.”
- The American College of Emergency Physicians
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“Bloopers”
Patient is able to remove his neck, but it does cause some discomfort.
Patient has two teenage children but no other abnormalities Explained to the family that patient was at death’s door and
we were trying to pull him through Patient suffered cardiac arrest. Resuscitation attempts failed
and patient pronounced dead. Patient requests an autopsy. Skin: Somewhat pale, but present. On the second day, the knee was better, and on the third
day, it had completely disappeared.
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Patient Assessment & Documentation
Illness Assessment– Head to Toe
Injury Assessment– Head to Toe
Acronyms
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Patient Care Documentation
PCR must be completed on every call PCR must be complete for every call Proper abbreviations, words, and
attitude Readable, professional, and adequately
reflect the care given or offered to patient
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Patient Care Documentation
Quotes where appropriate and required
Copy given in receiving hospital for attaching to permanent medical record.
Refusal form and incident report completed
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Patient Refusals
First we must understand that a competent adult has the right to refuse treatment and/or transportation.
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Patient Refusals
The EMS Providers Challenge:
To distinguish incompetence from bad decision-making.
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Patient Refusals
Patients who request to sign AMA Patients who are allowed to sign AMA Patient requests treatment - but no
transport Patient requests transport - but no
treatment
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Patient Refusals
Patients who should go to a hospital
Patients who must go to a hospital Patients with life threatening
illness/injury
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Patient Refusals
The EMS provider must always keep the best interest of the patient at the forefront
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Refusal Information Sheet
A document that provides information to the victim/patient regarding their refusal of services and offers added protection to the EMS provider.
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Refusal Check List
This check list is used to assist the EMS provider in a systematic approach to assure all venues have been exhausted during the consideration of patient refusals.
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Patient Evaluation Sheet
The EMS Cognitive Evaluation sheet assists with “elements of perception” in the determination of the victim/patients level of competence.
“Raise your right hand”
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Service Transport Form
Competent patients maintain the right to refuse medical care and/or transportation. This sample Refusal of Service/Transport form builds from previous examples to aid EMS providers when attempts to treat/transport have been exhausted.
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The Patient Care Report
Misspelled words, illegible hand-writing, and poor writing skills lend themselves to questioning the credibility of the care provider
“Just the Facts Ma’am”
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Scenario #2
76 y/o female c/o chest pain, nauseated, and dizzy.
PMH: Angina, Gall Bladder Operation
MEDS: Nitro, ASA, Vitamins Allergies: PCN Vital Signs:
– 204/98, P-56, R-28– 198/92, P-52, R-24
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Sample Patient Care Report Form
Although Patient Care Report forms vary in design, content is often the same. Several PCR’s are available for review and discussion.
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Scenario #3
26 y/o male walking around acting inappropriately post MVA.
Victim is bleeding from head.
Possible alcohol consumption
PMH: unknown Vitals: Victim does not
permit V.S. to be taken.
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Scenario #4
66 y/o male c/o tightness in his chest.
He permits Rx but refuses Tx. PMH: Angina, Gall Bladder
surgery 10 years ago. Meds: Nitrostat, ASA Allergies: MS Vitals:
188/98, P-116, R-24
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Incident Reports
Treatment Errors Equipment Malfunctions
– Medical Devices Act
Domestic Situations Vehicle Malfunctions/Crashes Other
– Infectious Disease Exposure, etc...
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Incident Report FormIncident ReportReference Number: _________________ Date: ______________ Shift: 24-08; 08-16; 16-24Incident Type: ________________________________________________________________________Unit #: __________ Time of Incident: _________ Time of Report: _________Personnel Involved: ___________________________________
_________________________________________________________________________________________________________
Incident Description:__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
(continue on separate sheet if necessary)
__________________________________ ___________________________________Signature: Provider completing Report Signature: Supervisor receiving Report--------------------------------------------------------------------------------------------------------------------------------
-Department Use Only-
Resolution: Date: ___________ Time: ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
__________________________________ ____________________________________Signature: Investigating Supervisor Signature: Chief of Operations
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Medical Direction
Medical Direction is not only a necessity but an asset to any EMS organization.
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The Quality Process
EMS personnel should consider the Quality Process as an intricate part of their everyday function.
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The Quality Process
The Seven Key Action Areas
1. Leadership
2. Information & Analysis
3. Strategic Quality Planning
4. Human Resource Development and Management
5. EMS Process Management
6. EMS System Results
7. Satisfaction of Patients and Other Stakeholders
-Malcolm Baldridge Quality Program
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Summary- What Can/Should We do?
Prospective QA/QI Active Medical
Director Peer performance
reviews Regular case reviews Protocol
review/testing
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Summary- What Can/Should We do? (con’t) Computer based PCR
w/ protocol compliance
PCR reviews - staggered by length of experience
Skills review & testing