the vermont department of health pre-hospital documentation vermont emergency medical services last...

The Vermont Department of Health

Pre-Hospital Documentation

Vermont Emergency Medical Services

Last updated October 2006


An Actual Run Form

Upon our arrival, found pt in bed with first responders complaining of breathing difficulty. Pt. physician saw her yesterday. Had cold X 2 weeks. Physician said lungs were congested. Nauseated, no vomiting. Upon listening to lung, equal but noisy. Pt initially put on 4 liters nonrebreather, complained so we used 24% Venturi. Allergic codeine. Dr. Bitlett. Pt diabetic due for insulin 8:00. Meds insulin.


An Actual Run FormUpon our arrival, found pt in bed with first responders complaining of breathing difficulty. Pt. physician saw her yesterday. Had cold X 2 weeks. Physician said lungs were congested. Nauseated, no vomiting. Upon listening to lung, equal but noisy. Pt initially put on 4 liters nonrebreather, complained so we used 24% Venturi. Allergic codeine. Dr. Bitlett. Pt diabetic due for insulin 8:00. Meds insulin.


Session Goal

At the end of this session, the student will be able to use the Vermont EMS Incident Report Form to document a pre‑hospital call in a systematic and complete fashion.


Learning Objectives

At the end of this session, the student will be able to:

1. describe the SOAP or CHART method of charting 2. list at two principles of writing a narrative

3. describe the role of documentation when a patient refuses care or transport

4. describe how care administered to a patient in a multiple casualty incident is documented


Learning Objectives

5. given pieces of information (in random order) about a call, properly document the assessment and treatment of the patient

6. describe the procedure to use when adding or correcting information on the run report form after the copies have been separated

7. (for Advanced EMTs only) list the pieces of information which should be recorded on the run report form when the EMT administers advanced life support in the field.


What This Session Will Cover

Importance & Purposes of Documentation

Frequent Problems (and Solutions)

Completing the VT EMS Incident Report Form

Exceptions and Special Cases Demonstration and Practice


Purposes of Documentation

educational • properly done within HIPAA

requirements

administrative• statistics and billing

research



evaluation and critique• What proportion of patients with a

chief complaint of difficulty breathing receive high concentration oxygen?

continuity of treatment in hospital



legal• form is not evidence in itself• becomes evidence as part of testimony of

witness to authenticate it • can be used to refresh the memory of a

witness• retain original for legal purposes


Kinds of Errors

incomplete or incorrect blanks and boxes (e.g., date)

SOLUTION? have someone else check the form


Kinds of Errors

incomplete or incorrect narrative (e.g., description of a patient's injuries without mentioning that he was in a collision

SOLUTION? use an outline to remind yourself what information

to include


Kinds of Errors

form reflects incomplete assessment or poor care

SOLUTION? document extenuating circumstances

combative patient language barrier pt refusal to cooperate extrication difficulties delay in response, at the scene, or en route to ED


Kinds of Errors

form reflects incomplete assessment or poor care

SOLUTION? if deviation from the usual treatment protocols

occurred, explain why; do not try to cover up errors or omissions in care


The Vermont EMS Incident Report Form

or Patient Care Report (PCR)


PCR Demographic Info


Code 2/Code 3

Any use of lights OR siren = Code 3


Nature of Call/CC

Fill in the chief complaint or nature of call as found, not as dispatched


Treatment & Vital Signs


Level of Treatment & Transport

Fill in treatment based on what the agency completing the form did for the pt

Fill in transport based on treatment the pt is receiving, regardless of who gives it


Trauma Score

Complete for trauma patients only

Use information from earliest EMS assessment

Let the hospital worry about adding up the numbers


Vital Signs

Repeat VS frequently Put SpO2, blood glucose, etc. in comments


Vital Signs

As needed, draw lines to make additional boxes for vital signs


A System for Comments

S

O

A

P


The SOAP System

Subjective

Objective

Assessment

Plan


Another System for Comments

C

HART


The CHART System

Chief complaint

HistoryAssessmentRx (treatment)Transport


SOAP

Subjective• Chief Complaint (CC)• History of Present Illness (HPI)• Past Medical History (PMH)


Subjective/History

History of Present Illness (HPI)• O• P• Q• R• S• T• U


Subjective/History

History of Present Illness (HPI)• Onset• Provokes• Quality/Quantity• Region/Radiates• Severity• Time• Undo+ associated symptoms


Subjective/History

Past Medical History (PMH)• M A• A M• I P• D L• S E


Subjective/History

Past Medical History (PMH)• Medications Allergies• Allergies Medications• Illnesses Pertinent past history• Doctor Last oral intake• Surgery Events leading to illness

or injury


Objective/Assessment – Trauma

pt appearance, position and surroundings head, eyes, ears, nose, throat neck chest abdomen and pelvis extremities


Objective/Assessment - Cardiorespiratory

pt appearance, position and surroundings neck – jugular veins chest – lung sounds extremities – pedal edema other – oxygen saturation, EKG as

appropriate


Objective/Assessment – Altered Mental Status

pt appearance, position and surroundings mental status• AVPU• orientation• memory• loss of consciousness


Objective/Assessment – Altered Mental Status

pupils trauma exam, including movement of

extremities other • blood glucose• oxygen saturation, EKG as appropriate


Exercise #1

In the first blank for each phrase, indicate what kind of information is given by using Hx for history and PE for physical exam.


Principles of Narrative Comments

Include pertinent negatives.• If a pt c/o chest pain, document the presence or

absence of .




absence of difficulty breathing.




absence of difficulty breathing.• If a pt c/o a blow to the head, document whether

or not the pt .




absence of difficulty breathing.• If a pt c/o a blow to the head, document whether

or not the pt lost consciousness.



Describe, don’t conclude.• “A well known, unshaved, unkempt, foul-smelling,

slightly cyanotic, 62 y/o alcoholic gentleman was carried into our emergency room by three million lice, all screaming, ‘Please save our host.’”

- from an actual doctor’s note shown to a jury in a malpractice suit in 1977



Describe, don’t conclude.• Pt had slurred speech, frequent mood swings

between happy and combative, inability to walk without assistance and odor of alcoholic beverage on his breath.

• Is there any need to say this pt was drunk?



Record important observations about the scene.• Suicide note found next to pt



Avoid radio codes on the form.Code 11, 33, 55, 77

In the 1970s in some parts of Vermont, this meant:

Code 11 = emotional disturbance

Code 33 = overdose

Code 55 = alcohol intoxication

Code 77 = attempted suicide



Use only standard abbreviations.• NOT, for instance

CTD

(circling the drain) HIBGIA

(had it before, got it again) FTD

(fixing to die)



Include changes in the patient’s condition after treatment or while en route.• After 1 tube of oral glucose, pt became lucid and

thanked us profusely.



Identify the source of information when it is not the patient.• Per wife, pt has used cocaine for 2 years.


Spelling

medication names


Spelling

orient

orientate X


Spelling

clavicle

clavical

X


Spelling

dilated

dialated

X


Spelling

crepitus

crepidusX


Spelling

prostate

prostrate

X


Spelling

palpitation

palpation

X


Spelling

seize

seizure

(verb)

(noun)


Spelling

diaphoretic

sweaty


Punctuation

Who says punctuation doesn’t count?


Punctuation

Pt experiences difficulty swallowing tires easily.

OR Pt experiences difficulty swallowing, tires

easily.


Punctuation

She moves her bowels roughly, three times a day.

ORShe moves her bowels roughly three times a

day.


Confidentiality

Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule• It’s not just the form that’s confidential, but the

medical information about the patient.• HIPAA applies whenever your service bills a pt.• Even if a pt doesn’t get a bill, the EMS agency and

providers are expected to maintain confidentiality.


Exceptions and Special Cases

Multiple Casualty Incidents Refusal of Care


Multiple Casualty Incidents

Use Met-Tags or local approved equivalent

Standard of care for documentation is different in an MCI


MCI

In an MCI, fill out tag as completely as circumstances allowAfterward, use tag to complete PCR the best you can


Refusal of Care

Vermont Supplemental Report for Patient Non-Transports• to be used with non-

transport protocol• to be completed in

addition to PCR• available free from EMS

Office


Refusal of Care


What About Other VT EMS Forms?

VT EMS no longer collects • Cardiac Arrest Report Forms or • Esophageal Tracheal Combitube Forms

Follow district medical advisor’s directions Both forms are available free of charge from

VT EMS Office


Learning from Others’ Experience

Evaluate the following narratives and describe how they could be improved.

Note: Information has been typed for ease of reading, but these are actual forms.


Example # 1

Pt has not been feeling well X 1 day. At 4:00 am this date pt started vomiting and uncontrollable bowels. Aching in both arms & shoulders. Pt had a temp. of 39.1 at this time. Pt has taken Datril one at 0116 and again at 0430 this am. No meds. No doctor. No allergies

942 88 98/60 20

1009 124 80/Dopp 17

(20 y/o female)


Example # 1

Strengths?• two complete sets of VS

en route to hospital

Improvements?• disorganized• skimpy (what was the

chief complaint?)• recognize and treat

shock when your patient has it


Example # 2

R compound open femur fracture. Lacerations – inner R thigh, R ankle, R toes, R little toe underneath. Abrasions – both elbows, 4 burn marks 1 ½” diameter in thoracic/lumbar region of back. femur fracture w/ bone coming thru medial aspect approx 3” above knee. Open wound approx 3” long lateral aspect approx 2” above knee 1 open wound with great deal of bleeding from medial aspect of wound. Contusions & lacerations to tib/fib area of R leg. Pt. has good motor function of the toes on the R leg and good distal pulse. Pt drowsy and difficult time getting radial pulse. Pt had no guarding in abdomen breath sounds good. NKA, NKM. Pt took off helmet and jacket prior to arrival.

1450 R/L KVO 16 ga LAB


Vital Signs – Example # 2

1427 56 84/P 80Both legs of MAST inflated

1450 68 104/D


Example # 2

Strengths?• detailed descriptions of

injuries• recognized and treated

shock

Improvements?• What happened (how

was pt injured)?• Pre-MAST vital signs?• Was initial respiratory

rate really 80 per minute?


Example # 3

68 y/o male found lying face down on bedroom floor, had vomited. Pt responsive to verbal stimuli, could answer questions with single words, but could not tell us what happened or speak understandably. Able to move all extremities, oriented to person only. Large contusion L forehead, small abrasion on R forehead and upper bridge of nose. Pupils constricted. Wife reports hx stomach problems but was very upset, unable to give good history.


Example # 3

Strengths?• good description of

abnormal mental status• good explanation for lack

of history

Improvements?


Example #4

Arrived to find alert oriented X 3 28 y/o female c/o substernal pain that started approx 4 hrs ago and has been constant. Pain radiated into back. Skin warm, dry & pink. Pain felt as something heavy. Lungs clear & equal bilaterally. Had stress test earlier today – results unknown. Transported with 10 lpm NRB in Fowler’s position. M: Axid. A: N/A. I: Mitral valve prolapse. D: McDonald. S: 1988

Hysterectomy.2000 108 128/96

24

2018 112 130/P 28


Example # 4

Strengths?• good description of

history of present illness• two complete sets of vital

signs

Improvements?• nonstandard

abbreviations


Correcting Information

Before form submitted:• if small error, draw single line through it and initial

it• agency may require date and time, too• if large error, start new PCR

Do NOT try to obliterate error• appears EMT was trying to hide something


Correcting Information

After form submitted:• if information important, EMT who wrote PCR

should use separate piece of paper to: note reason for addendum and why it was not in original

report note date and time of addendum describe additional or corrected information

• Attach to PCR• On original form, write “See addendum”


IV Fluids & Medications

When a slash separates two words in a box, the word to the left of the slash is for IV fluids and the word to the right is for medications.

IV fluids



When a slash separates two words in a box, the word to the left of the slash is for IV fluids and the word to the right is for medications.

Medications



Remember to extend the box lines before writing your narrative.


Exercise #2

Work in small groups and organize the information on the cards so that it fits the SOAP or CHART format.


Summary

Have a system for completing the PCR Have someone else check the form Beware spelling and punctuation pitfalls Use non-transport form when appropriate

the vermont department of health pre-hospital documentation vermont emergency medical services last...

Documents

form slide

care slide

hospital slide

practice slide

documented slide

comments slide

dispatched slide

legal purposes slide