Charting

The Patient and Family

• The average person has contact with 9-1-1 twice in their lifetime

• Is it an emergency or not?

• How much do you tell them about what’s going on?

• What about confidentiality?

Radio Communications

• Why do them?

• Be concise

• Use standard format

Radio report should include• Unit calling• Pt age and gender• Name of primary physician• Chief complaint• General condition• Pertinent history• Management• ETA

• Repeat orders back to verify

• Clarify prn

Report at ED bedside

• Introduce pt.

• Use same logical format

• Include pertinent negatives and

positives

• Include information about allergies

and meds

The written record

• A story– Logical beginning– Logical ending– Bulk of the material in the middle

• Report must be:– Complete – Accurate– Legible– Left at hospital before clearing call

Written record, cont.

• Must be signed by both PIC and

partner

• Limit statements to the facts.

• No assumptions or judgments

Charting, cont.

• DON’T make discriminatory statements

• Don’t swear on charts– “get the H**l out of my house”

• Use quotations

• Do use accepted abbreviations

• Draw single line through errors and initial them

• Document findings, especially pertinent negatives

• Will you remember details in 27

years?

Pearls for charting

• Don’t let your paperwork interfere with patient care

• If information is not recorded, it was NOT DONE.

• If you didn’t do it, don’t write it down• Don’t document opinions• If you forgot it, don’t forget it next time• If you ever need it, this is your only

defense

Charting formats

• Flow chart

– Fills out the story

– Must include baseline vitals, as well

as at least one other set

– Document times

Medications

• Critical for DDx

• Include dosage and dosing regimes

for certain meds

Allergies

• May influence treatment

SOAP format

• Subjective– Beginning of story

• Objective– Middle – most difficult part– Document head to toe– General assessment vs focused

assessment

SOAP format, cont.

• Assessment– Or R/O; what do you think is wrong?

• Plan– What did you do to fix the problem?– What response did the patient have to

your tx?– How was the patient physically

transferred?– Bed rails up or down?– Whose care did you leave pt in?

Did you?

• Record all information needed by others?

• Adequately state all your observations about pt.?

• Support your clinical impression?• List all care given to pt?• Use only recognized abbreviations?• And your partner sign the form?

And finally…

• Is your information complete

enough so that you could

reconstruct the entire situation and

defend your actions later if

necessary?

CHEATED format

• Complaint• History• Exam• Assessment• Treatment• Evaluation• Disposition

Refusals

• Decision-making capacity– The ability to make an informed

decision

• Impaired decision making capacity– The inability to understand the nature

of illness or injury, and the risks and consequences of refusing care

Impaired decision making capacity (IDMC)• Alcohol ingestion• Use of drugs• Altered mentation from any medical

condition or trauma

• Don’t use “competent” or

incompetent”

IDMC

• Don’t have impaired person sign refusal form

• Treat and transport any person who is impaired

Documenting refusals• General appearance• Vitals• H & P• Mental status• Presence of drugs or alcohol• Assessment of decision making capacity• Risks explained and advice offered• Response to efforts by EMTs to provide

care• Communications with law enforcement,

family, OLMC, pt.

Patient refusal definitions

• 18 y/o or older• No significant mechanism of injury• No significant signs of trauma• No acute medical condition• No behavioral conditions• No comorbid factors

Reporting requirements

• Suspected abuse– Child– Elder– Dog bites

Summary

• Document to establish a record of care provided

• Document to protect yourself and agency from questions