documentation (updated 4 2011)

“If you didn’t write it……You didn’t do it!

Documentation

L. Kelly Kirk, III, A.A.S., B.S., EMT-P

Documentation

Documentation is very important:It is a written record of the incident that can be

used in the near or distant future for tasks such as:

Information about scene and transport care so the receiving practitioner can provide additional patient care.

Follow-up on patient care (QA/QI) by EMS service

Legal documentation for criminal and civil courts

It is a legal record of the incidentthis may be your only source of reference to a specific

call


Documentation

Importance:Documentation provides a record of support

services that have been used and time frames in which they were used:HelicopterCoroner,Rescue / extrication etc.Law Enforcement

Provides documentation of services performed so billing can be accomplished accurately, timely, and effectively.

Kellyology!Face it, this is where the money is coming from for

most services! If you wanna tick off your bosses, start cutting into the money they are making!

Elements of a Properly written EMS Document

Accurate

LegibleBecoming less of an

issue now with electronic PCRs.

TimelyCompleted and

submitted as quickly as possible following the call.

UnalteredIf alterations are

necessary, make sure they have been complete properly and added to all outstanding copies (hospital, billing, etc.)

Free of non-professional/extraneous information


Documentation

AccurateThe accuracy depends on each piece of information

on the report:Being comprehensive, yet precise and to the point.Report what you see, do, hear, smell, and feel as long as

it is pertinent and relevant to your patient care

Make sure each area of the report has been filled out completely.

Kellyology!Look, we all hate extra steps and boxes to check, and YES if you

don’t fill out certain boxes you will still be able to close the report and submit it. However, in the end, the report will either come back to you, your service will not bill the patient as much as should have been, or payment will be delayed while someone is trying to figure out what you should have done. Either way, take the time to completely fill out the report so everyone is happy and more importantly, you patient is properly cared for!


Documentation

Legible: (Handwritten ACRs)

Any checkbox markings are clear and consistent through all carbon copies.

Handwriting, especially the narrative can be read by others* with ease.

*See “Kellyology” next slide.


Documentation

Kellyology!Now lets face it…some of us can read chicken

scratch better than we can our own hand writing!

Think about this…3 years and hundreds, if not thousands of calls later, this will be the only way we can recall some of this information if we go to court. Take an extra minute or two to PRINT the document and make it legible. You will appreciate it later on!

NOT TO MENTION: Some people actually get subpoena's JUST TO READ THE ACR…because nobody else can make it out! A legible ACR can save you an unnecessary trip to the court house or lawyer’s office.


Documentation

Spell Checked and Grammatically Correct.

Use the “Spell Check” feature to correct your typos and spelling errors.

Use your ALS Pocket Guide notes area to write commonly misspelled words (especially medical terms that may not be in the electronic spell check yet.)

ConsciousBeautifulDefinitelyHemorrhageDiarrhea Sheriff


Documentation

Kellyology! (Grammar & Spelling)

OK….OK….stop throwing stones at me and hear me out!Yes, some of us can’t spell to save our lives! (Thank God for spell

checker!) Matter of fact, I remember we used to literally dig through the PCR (Pre-HIPPA of course) pile to see if particular people had submitted reports. We would literally have guys come from all over the station to hear the newest “MAD LIB” report. We read aloud each of the reports. Sometimes as many as 3 or 4 times. At first we thought this guy was working in a new age ambulance with equipment only available to him. His ambulance had cafaters, spin broads, ocksagen, butatrols, epenefren and a variety of other unusual items. To this day we have yet been able to find any of these on the other units!

OK…sorry I digressed! But seriously, your report is a reflection of your professionalism. Heaven forbid you are facing a “Johnny Cochran” wannabe when your

report is called into evidence. An attorney that is trying to get your PCR or your testimony thrown out or at least, make it look bad, will JUMP all over poor grammar and spelling and any other nit-picky item he/she can find that will cause the jury to question your credibility. Ever heard the term “Reasonable Doubt?” If not, just wait for your turn at jury

duty.


Documentation

Kellyology! Electronic PCRsOH…and while I’m at it….make sure you

take time to write a descriptive narrative on all your calls. Have you taken the time to look at and

compare print-outs of your electronic call reports? They are all practically IDENTICAL. Aside from the patient specific information, these reports may not be as easy for you to recall specific information from the call without a detailed narrative.


Documentation

TimelyDocumentation should be completed ideally before

the paramedic handles other tasks. Especially additional calls or patient contacts

More Kellyology!Trust me, if you have never had one of those days where

it is one call after the other, just wait, you will! And then when you are finally writing the first report of the last five calls, it will go something like this: “Was his blood pressure 150/90 or 160/90 and was the pulse 90 or 80?”

No big deal either way right? What if the patient is an elderly patient who fell? Your original

vitals were 160/90 p. 80 the hospitals vitals 30 minutes later was 170/84 p. 70, and again 30 minutes later 184/70 p. 60. Is it significant now? If you think not, try reading information about cushings triad and intracranial pressure.


Documentation

Unaltered

Written ACRsAll mistakes have a

single line drawn through them then date and initial the change(s)

Computerized ACRsMistakes should be

corrected prior printing or submitting

Corrections after submission:

• Your computer program vendor should have a method in place for correcting errors while still tracking the changes. Printed copies at facilities should be corrected just as a traditional ACR with single line and initials.


Documentation

Free of non-professional/extraneous information

JargonSlangBiasLibel / slanderIrrelevant opinions or impressions

Document Revision / Correction


Documentation

How To Revise a Document

Written ACRs• Write revisions on separate

report forms

• Note the purpose of the revision and why the information did not appear on the original document

• Note the date and time of the revision

Computerized ACRs• Usually completed by

re-opening the ACR and making an addendum• Including date,

time, purpose, and whom

• Print a new copy of addendum and submit to facility and all additional locations of original copies.


Documentation

Who revises the document?

Revisions should be done by the original author of the document


Documentation

When?When the need for revision is realized, it

should be done as soon as possible


Documentation

Acceptable methods

Written ACRsCorrections

Written narrative is appropriate, on a new report form which is then attached to the original

Deletions and additionsshould not be done on the original report form they should only be done on a new report formMistakes have a single line drawn through them and initialed, larger deletions that should be made are done on a new form and attached.

Computerized ACRs• Corrections made to the

original ACR should have some method to track the changes and not just delete old material. (Work with your software vendor to assure this is the case.)• A copy of the revised

PCR can be attached to the original with updated date and other information.

• Never delete information entirely, it should be kept in the document with notes showing that the information was moved/changed/rewritten.


Documentation

Acceptable methodsWritten ACR

Supplemental narrativesIf more information

comes to the paramedics attention, a supplemental narrative can be written on a separate sheet of paper and attached to the original document

Ultimately, copies of these additions should be attached to ALL copies of the original ACRHospital Copy etc.

Computerized ACRSupplemental

narrativesIf more information

comes to the paramedics attention, a supplemental narrative can usually be added to the original report

Ultimately, copies of these additions should be attached to ALL copies of the original ACR

Systems of Narrative Writing


Documentation

Head to Toe approachThe narrative uses a comprehensive,

consistent physical approach starting from the patient’s head and going all the way to the feet.


Documentation

Body systems approachThe narrative uses a comprehensive review

of the primary body systems.RespiratoryCardiacNeuro-muscularetc.


Documentation

Call Incident ApproachUses a narrative that describes the call as it

happened in chronological orderExample:12:00 dispatched to incident12:03 arrived on scene12:04 arrived at patients side to find the

patient lying supine complaining of pain12:06 patient loaded with full spinal protocol

etc.


Documentation

S.O.A.P

SubjectiveWhat the patient tells you

“my chest hurts”Objective

What you see, hear, feelPatient is pale, diaphoretic.

AssessmentWhat you find when you assess the

patientVital Signs

PlanWhat did you do for the patient

Placed on oxygen at 10 lpm


Documentation

C.H.A.R.T.E.Chief ComplaintHistory

Includes HPI (History of Present Illness)AssessmentRx. (Medications & Allergies)TreatmentEvents

Any events etc. That are out of the ordinary.


Documentation

Disclaimer:The previous methods are just a few of the many

different methods used to record patient narrative information. You may use a different method for documenting or you may use different versions of the same (CHARTE, CHARTED, Etc.) versions. What is important is that the method used helps systematically approach the documentation so all pertinent information has been captured. With the proliferation of electronic ACRs, more and more documentation is becoming a simple click to check the box. These electronic ACRs are being set with “rules” that force you to record pertinent data before you can “close” the call, helping you more completely document the call.

Special Considerations of Documentation


Documentation

Documentation of RefusalsWhen a patient refuses medical care the

paramedic must show in the report the process undergone to come to that conclusion INCLUDING:Advise to patient from Paramedic and

Medical controlSignatures of witness(es) to the event Complete narrative including quotations or

statements of others


Documentation

Document decisions/events where care and transportation were not needed

If cancelled enroutenote who cancelled and time cancelled

If cancelled at scenenote who cancelled and special circumstances

ex. Upon arrival Police officer advised no injuries and asked us to leave the scene, no patient contact made (14:35)


Documentation

Documentation in Mass casualty situations

In unusual situations such as MCI, comprehensive documentation has to wait until after the call

Due to the number of patients seen during an MCI notes should be kept to help the Paramedic(s) with documentation.This can be accomplished by:

Small note pad including pt. Name and complaint

Use of triage tags www.jimdiffin.wordpress.com

Consequences of Inappropriate Documentation


Documentation

Implications to medical careAn incomplete, inaccurate, or illegible

report may cause subsequent care givers to provide inappropriate care to a patient


Documentation

Legal ImplicationsA Lawyer Considering the

merits of an impending lawsuit can be dissuaded from a case when the documentation is done correctly.

The converse is also true if documentation is anything less a lawyer can decide to take the case to court and “pick apart” the EMS Report.


Documentation

REMINDER:An attorney can (and will) attack the

credibility of a medical professional by “picking apart” his/her documentation and pointing out all the misspelled words, misused abbreviations, and poor grammar.

You may be one of the best paramedics in the service when it comes down to actual patient care, but if your documentation is done poorly, you will look (on paper) like a rookie!

Thank GOD for electronic ACR’s and SPELL CHECK!


Documentation

In Closing…..Documentation is a maligned task in EMS,

but one of the utmost importance for a variety of reasons. A professional EMS provider appreciates this and strives to set a good example to others regarding the completion of the documentation tasks.

Don’t be one of those who are constantly called to the boss’s office to read, correct, or update and ACR!

documentation (updated 4 2011)

Education

patient specific information

documentation of services

timely documentation

additional patient care

patient care qaqi

patient contacts

electronic spell check

piece of information