5)Documentation

Documentation

Prehospital Pt Care Report (PPCR)

• What• Standardized pt record

used in EMS• Systematic collection of

data from dispatch through tx to hospital

• Functions• Documentation of

• pt C/C, MOI, NOI, Hx, and treatments, refusals

• Some items• Time – Location –

Assessments – Rx – Changes in Condition

PPCR Functions

• Medical Record• Continuity of Care

• Medical report of prehospital care• Physician review for treatment• MOI, NOI, Chronology of S/S, Vitals, etc

• Educational• Demonstrates proper documentation • How to handle unusual situations/events

• Administrative • Billing• Service Statistics• Research• Evaluation/CE• Continuous QI

• Improving different components of EMS through evaluation of call sheets and pt Rx

PPCR Functions

• Legal Document• PROTECTION FROM

LAWSUITS • IF YOU DON’T WRITE IT

DOWN YOU DIDN’T DO IT!!!!!!!!

• Generally the writer is the one who goes to court with the PPCR

• Accurate times• Status of pt upon arrival at

scene, during tx• Emergency treatment

provided• Changes in condition en

route to hospital• Any unusual events that

occurred during the call

PPCR ComponentsMinimal Data Set

• Pt Information• C/C• LOC• Vital signs

• B/P• Perfusion status • Pulse Rate• Resp Rate and Quality• Skin Color and Temp

• Administrative Information (Military Time)• Time call was reported• Time unit signed en route• Time unit arrived on scene• Time of arrival at pt• Time unit left scene• Time of arrival at destination• Time of transfer of care

PPCR Types/Sections

• Types• Traditional written form • Digital/Computer based

• Run Data• Date – Times – Unit # - Service – Crew Names

• Pt Data• Name – Address- DOB – Insurance Info – Sex – Age• NOI/MOI – Pt Location – Rx given prior to arrival• S/S – Rx administered – Baseline Vitals – SAMPLE Hx• Changes in condition -Receiving Facility – Specialty Tx mode• Rationale for receiving facility

• Check Boxes• Be sure to fill in box completely• Avoid stray marks

PPCR Narrative

• Narrative • Describe, don’t conclude• Include pertinent negatives• Record observations about

the scene• Avoid radio codes• Use standard abbreviations• When sensitive information

is obtained note the source• State reporting

requirements• Spell correctly • For EVERY assessment

record time and findings.

Narrative Methods

• C.H.A.R.T.• Complaint• History• Assessment• Rx-Treatment• Transport

• S.O.A.P– Subjective

What Pt/bystanders says in their “own words”

– C/C, SAMPLE/OPQRST

– Objective What YOU see/measure in

assessment– Scene size up, Assessment

findings, Vitals,

– Assessment What YOU think is wrong

– Conclusion/Clinical impression

– Plan Treatments occurred, treatments

planned

C.H.E.A.T.E.D.– Chief Complaint– History– Examination– Assessment– Treatment– Evaluation

Did treatment help– Disposition

Final outcome

PPCR Distribution

• Confidentiality• The form and its contents are confidential

• Distribution• Determined by local and state protocols

• Written release not needed…• Receiving facility,Transporting agencies • Continuation of care • 3rd party billing info• Continuing education (remove pt ID)• Sate law (rape, abuse, GSW)• Subpoena

12VAC5-31-950. Disclosure of patient information.

PPCR Falsification Issues

• Error of omission/commission • Document what did/did not happen• What steps if any were done to correct it

• Falsification• Revocation of certification• Improper pt care due to incorrect assessment

• Areas of difficulty• Vital Signs

• Document on the ones there were TAKEN• Treatments

• Do not chart procedures there were not performed

Pt Refusals

• COMPETENT adult pt have the right to refuse care at any time

• Before you leave the scene you should:

• Try to persuade pt to go to hospital• Ensure pt is able to make informed

decision • Inform pt of why he/she should go &

what could happen if he/she does not go

• Consult med control if need be• If pt still refuses

• Document assessment findings• Document any Rx• Have pt sign refusal • Have a family member, by stander,

police sign as witness• If pt refuses to sign refusal

• Have a family member, by stander, police sign as witness

Pt Refusals

• Complete PPCR • Complete Pt assessment• Care EMT-B wished to

provide to pt• Statement that the EMT-B

explained to pt possible consequences of refusal including death

• Offer alternative methods of obtaining care

• State willingness to return

Correcting Errors in Documentation

• Errors made while writing PPCR• Draw single horizontal line through error and initial it• Write correct info beside line• Do not attempt to obliterate the error

• Errors discovered after report has been written• Draw single horizontal line through error• Initial and date it• Attach a note with the correct info• If info was omitted attach a note with date and EMT’s initials

Special SituationsMass Casualty Incidents

• MCI• Use of Triage Tags

• Basic Pt ID data• Major Injuries• Baseline Vitals• Triage Status

• Local plans have guidelines for MCI

• When there is not enough time to fill out report before next call:

• Fill the PPCR out later

Documentation of Death

• Documentation of Death• Withholding treatment if irreversible brain damage can be proven

in pt in cardiac arrest• Note ALL factors that denote obvious death including/but not

limited to :• Decapitation• Transection of chest and/or abd• Rigor mortis• Lividity• Decomposition• Charring of the body• Extensive head trauma• Chest injury/trauma indicative of mortal injury• Other bodily disfigurement indicative of mortal injury

Special Situations

• Special Situation Reports• Used to document events that should be reported

to local authorities or to supplement primary report

• i.e. Exposure/Injury/Lost property

• Submitted in timely manner to authority per protocol

• Accurate and objective• EMT-B should keep copy for records

Effectiveness of PPRC

• Accuracy & Honesty• State C/C in pt own words

• “I hurt all over” “Feels like an elephant sitting on my chest”

• Accurate vital signs• Describe your findings NOT conclusions

• “Pt was found disoriented on the apartment floor with an alcohol-like odor on his breath”

• NOT• “Pt was found drunk on the floor of the apartment”

Effectiveness of PPRC Continued

• Clarity• Print legibly• Black/blue ink• Approved shorthand/abbreviations• Correct spelling• EXACT location of pain/injury

• “substernal chest pain”• “Puncture wound on anterior chest approx 3 cm off

midline”

Some Common Abbreviations

• Female Male • a= Before p = After • BP= Blood pressure• BVM = Bag Valve Mask• c= With s= without• c/o = complains of• CPR• DOB = Date of Birth, y/o = Year old • Hx = History• LLQ = Left Lower Quadrant, LUQ = Left Upper Quadrant• NTG = Nitroglycerin• O2 = Oxygen • po= By Mouth SL= Sublingual• Pt= Patient• Px= Physical Exam• RLQ= Right lower Quadrant, RUQ = Right Upper Quadrant• Tx = Treatment• NRB = Non Rebreather NC= Nasal Cannula

Effectiveness of PPRC

• Chronology and Trends• Time relationship of :

• Response- Assessment- Treatment – Transport – Arrival

• Provides physician with Hx of events• Provides trends and responses to treatment

• i.e. SOB pt c O2 = Relieved hypoxia – Improved O2 sats

Time Resp Pulse B/P LOC Pupils Skin1805 16 90 120 A PERRL Cool/Moist/Pale Regular Regular 80

18:10 22 110 110 A PERRL Cool/Moist/Pale Shallow Regular 84

18:15 28 140 90 Voice Dilated Cool/Moist/Pale Shallow Regular 70

What trends do you see? What do you think might be causing this???

Effectiveness of PPRC

• Completeness • Record all assessment, treatments, reassessments

• +/- findings• “Pt c/o severe squeezing chest pain on L side but denies

radiation” • Events that affected treatment/transport

• Prolonged extrications• Role of other providers on scene• Treatments provided by lay people

• CPR, 1st Aid• Other unusual occurrences

• Belligerent/aggressive pt • Removal of items from pt

One Last Rule…

Document…

Document…

Document…