Essential Guide to EMS Documentation

So let's get into it, all right? Chapter six, we're going over documentation, documentation in EMS. EMS documentation is an integral part of the patient care process. The patient care report, or PCR, may be called a pre-hospital care report as well. It is the only written record of the events that occur during the call for service. It is a legal record for the call, so all patient care reports are legal documents. That's why I was talking earlier this week, you know, about how critical your reports are. That report is considered a legal document. So it is basically admissible in court for evidence. So you have to make sure you are doing the right thing when you write those reports and always being professional. It becomes part of the patient's medical record and emergency department chart. It helps guide future patients and quality assurance. An EMS professional needs to know what constitute a PCR. what information must be included, who might read the PCR, when the PCR must be completed, and what terminology may be used. Information can be objective or subjective. So objective information is measurable signs that you observe and record, i.e. like pulse rate, respiratory rate, blood pressure. So basically all your vital signs, that's objective information. Anything that you can measure as fact. So your vital signs are basically objective information. Subjective information is information that is told to you, but that cannot be seen. So like symptoms that a patient has described, a degree of pain, nausea, how they're feeling, like all that stuff is considered subjective information. All right. So remember there's two types of information is objective and subjective. information. Know the difference between objective information and subjective information. The required information for the PCR, you have to have both objective information, subjective information, and the details of the patient's care. PCR must be complete, accurate, and legible. It can be the basis of a defense and legal proceedings. Like I told you guys, it's a legal document, so it has to be legible. That's why 99% of, I think, all EMS providers, they got tablets. So everything is typed out because you all know people handwriting is not the best. So most EMS systems, everybody has a tablet that they can do their reports on. This PCR also facilitates quality and continuity of care and is used to bill insurance. So the report is sent to the insurance agencies, whatever is in that report, so they make sure everything lines up between the hospital and EMS so they can bill for the appropriate. things. They don't want to have disconnects. So a lot of times when people get their bills back from the hospital, depending on what happened in the ambulance, as opposed to what happened in the hospital, you'll get discrepancies. And you know, insurance companies, they look for any reason to deny your claim. So you always want to make sure everybody's on the same page and everything lines up accordingly. So legal implications of the PCR. So reports may include subjective statements from the patient, but cannot include any personal bias or opinions a paramedic may have regarding the patient. Again, always be professional. Leave your personal feelings about whatever you're dealing with or your thoughts about the patient. Leave that out. It's always professional at all times. All right. PCRs that are poorly written or inappropriately documented could have adverse implications for patient care and for a paramedic's career. Emissions or errors could lead to further errors in care of the patient. Improper and inadequate reports can result in litigation, job loss or demotion, and poor reputation for you as an EMS provider. So again, your reports are... or key, man, whatever you put on that report, that reflects that it's a reflection of you. So always make sure those reports, again, accurate, clear, professional, because again, it is a reflection of you. All right. And again, it can be used against you in litigation. Paramedics have been found guilty of neglect based on the failure to perform patient exams and submit completed paperwork. So like we was talking about in our discussion board video a few days ago, the paramedics put that there was no patient found. So they documented that in a legal document. So what they were stating was, so basically that document says, hey, there was no patient found. They're putting that on pen to paper and tablet or whatever, stating that as facts. So now when that's presented in court, This is what happened. The woman's deteriorated and she ended up becoming unalive. You say you've never seen her. You say there was no patient care. Patient wasn't found. However, the family is stating that you guys did show up. You didn't do anything for and she drove herself to the hospital. So, again, that patient report, you make sure you document everything factually and accurately, because, again, when it come to when it come to court, when it come to putting it. stuff in front of the stand and it's your word your word don't matter no more whatever is in that report so make sure you are always accurate and being truthful in your patient care reports reports should be complete well written legible professional and the sole source of information about the call may be used in legal proceeding proceedings years after the call and it may be your only defense against a complaint about a call use proper spelling grammar and accurate terminology sloppy documentation implies sloppy care The Health Insurance Portability Act, or HIPAA, has ramifications related to patient care reporting. So again, guys, as it pertains to what I just talked about, so just for example, I've been in depositions. Depositions don't happen like right away, like immediately after a call has happened. I've had depositions that I've had to go to. A lawyer will call me and the call would have been from two or three years ago. And like, let's just be honest. Can you really remember two or three years ago in very like detail? Like certain things, yes. But like I see so many patients like, do you really think I'm going to remember something from three years ago with great, great excruciating detail? Obviously not. All I have is whatever is in that patient care report. That is my defense. So if I was sloppy with that report or. I had any inaccurate information or what I'm remembering doesn't line up with what's in that report. They're going to go off that report. They're going to go off whatever you wrote at the time. So whatever you wrote at the time, that's that's that's what it is. That's that's gospel. So make sure, again, be truthful, be honest, be factual, be professional whenever you're doing these patient reports. So purposes of documentation. All right. So purposes of documentation. So you want to have a continuity of care. So the PCR serves as a record of the patient's condition upon your arrival to the scene, the care that was provided, any changes in the patient's condition in route, condition on arrival at the hospital. The PCR should be accurate and clear to ensure better patient care at the hospital. The minimum requirements in billing PCR writing must be accurate and complete for billing and administration care at the hospital. The minimum requirements in billing, PCR writing must be accurate and complete for billing and administration. For complete and accurate revenue recovery, you must ensure procedures performed are documented, medical necessity signatures are obtained. Reason the patient needed to be transported by ambulance is documented. Inaccurate or incomplete documentation delays the billing process. Your agency may require additional billing paperwork. EMS research. So researchers use the information collected by EMS providers to justify innovative life-saving techniques. Many states now require EMS agencies to submit data to their state EMS office to verify call volumes and skills used, including the number of calls to which an agency responds to, the types of calls, the care that's provided, patient outcomes, patient outcomes, and also patient demographics. Patient care data collection can improve the EMS system as a whole. The National Emergency Medical Services Information System stores standardized EMS data from each individual state. This central, excuse me, excuse me. This central repository collects research nationwide to assist in future curriculum development. The goal of NMESIS, which is the National Emergency Medical Services Information System, is to define EMS care by collecting data to improve patient care, identifying equipment needs, and defining a standard of care across the nation. Incident Review and Quality Assurance. So occasional PCRs may be requested for medical audits and other educational activities. So run reviews are sessions where peers or other medical professionals review PCRs for adherence to local protocols, quality assurance and quality monitoring. Always accurately document skills attempted and performed during patient care. So even if you perform an intervention and it's unsuccessful, you have to document that. I document everything that you do. So let's say I'm starting an IV on a patient. For every IV I start, if it's successful or unsuccessful, I have to document that. So if I start an IV and I don't get it, I have to document that as, hey, IV started, attempt number one, unsuccessful. And then if you have to start, try another attempt. Again, IV started, attempt number two, successful, for example. Again, document everything. So most EMS reporting is done electronically. Electronic documentation has many benefits. It can be shared easily between the facility and personnel involved in the patient's care. It improves continuity and efficiency of care. It can be shared among state and national databases which improves national data collection. Some services have developed check boxes and drop down menus instead of instead of narrative sections. So it makes it easier and more efficient to do these reports. They upload a lot of information into these programs. So now we're just doing a lot of drag and drop or just drag and click, just drag and click. That way we get through these reports faster. We can get back into service faster so we can serve the next patient or be ready for the next call. The only problem with the checkbox format is it can present with a risk of errors. So that's why you always double checking the things that you check. Always double check what you're looking at. Don't just be starting to get automatic or robotic with it because you do so many because then you can make errors. And again, whatever is in that report is what's used against you if it ever gets bought up to court. Most agencies are shifting away from paper reporting. Paper reporting is a duplication of the work. If you're doing it electronically, you shouldn't do paper reporting as well. Paper requires storage. So again, you're getting all these paper documents, you got to store them somewhere. So obviously, you want to save space to keep everything electronic. Modern data systems incorporate data from various sources such as multiple facilities to improve patient care. So the result is one comprehensive record for the patient and electronic documentation systems should be Nemesis compliant. So whatever system that. your company is working in when you get into EMS, it all has to be nemesis compliant because again, it has to be able to be seen nationally if need be. So again, make sure that you guys, when you document and you're doing... these reports everything is accurate everything is professional i keep repeating it guys because it's it's so important it's so important man you don't want to be in no legal trouble for some paperwork or paperwork error that's that's a stupid reason to be uh that's a stupid reason to get involved or be in trouble legally documentation for every ems call So every EMS call requires documentation, regardless if you see a patient, the patient refuses to go to the hospital, a false alarm, everything needs to be documented. Any call you get, make sure you document what happened on that call. Even if we get dispatched in a 911 call and they cancel us en route, that's a patient report. We have to do a report. So even if it's something as simple as canceled en route, that keep everything documented, every call documented. The minimum data set is the mandatory clinical assessment standard information that must be documented on every call. It's set by Medicare and Medicaid. It's per the National Highway Traffic Safety Administration and it's for the purpose of the national data system. The minimum data set is divided into run data and patient data. So run data consists of incident times, locations, responding units, crew member names of the working of those working at the incidents. So again, the run number, the run data is basically the incident times, the locations, the responding units, and the crew members, whoever was working on the scene. The patient data includes basic patient information collected on the patient care report, such as the chief complaint, the level of consciousness, the vital signs, the assessments, and the patient demographics. The patient care report should document objective observations of the scene, i.e. living conditions, the mechanism of injury, other areas of concern, etc. Things of that nature. The treatments provided, the effects of those treatments, and changes in patients conditions during the emergency call. Depending on the type of transport, service treatments may need to be differentiated between scheduled and unexpected. An example of a scheduled treatment is a transfer report. Unexpected treatments result from changes in a patient condition. So transfer of care. When you're transferring care, it is important to document in whose care the patient was left to avoid allegations of abandonment. So when we talked about abandonment the other day, remember, you don't leave that patient until you've turned that patient over to a higher level of care. So if you've taken a patient to the hospital, you don't leave that patient until a nurse or a doctor takes responsibility of that patient and you make sure they sign that they took responsibility of that patient. And if you don't get a signature, let's say, for example, you take that patient over, you hand them to a nurse, y'all have a conversation, you give that person a rundown, you don't get that signature. Let's say that patient deteriorates or goes down, or the nurse does something wrong and something happens to that patient and that patient has a negative outcome. If that nurse really wanted to or she wanted to stay out of trouble, she could just say, I never touched this patient. When I got here, nobody gave me patient care report. I didn't know anything. And now you don't have that lady's signature that you talked with her and told her everything that was going on. Now it falls all the way back on you. So again, always make sure when you're dealing with the hospital, I don't care if you know the nurses or you know you got good relationships with these people. Hey, by the way, I need you to sign. Always cover your butt. I need you to sign. Give me your signature, please. Care prior to arrival. More emergency dispatch centers are shifting to a system called Emergency Medical Dispatch, or EMD. EMD allows the dispatcher to select the appropriate units to respond and provide directions to the caller for medical care and medication administration over the phone. When you encounter an EMD, it is important to obtain information from the patient or caller as to what care has been provided prior to your arrival, and document your findings. An example of what an EMD center might do is to prescribe aspirin to a caller experiencing chest pain. So an example of correct documentation of this will ensure the patient does not receive the same medication again. So you want to make sure that if your dispatcher gives any pre-arrival instructions, like, for example, if somebody's experiencing chest pain, the dispatcher will be like, well, do you have any aspirin at the house that you can take? And the patient's like, yeah, I have some. And the dispatcher will tell them, do you want to take 324 milligrams of baby aspirin or aspirin? The person takes that before you get there. Now, when you get there, you want to make sure that person and dispatcher communicate. to you like, hey, that person has already taken 324 milligrams of aspirin. So I know as a provider, they already have aspirin on board. I don't need to give them an additional dose of aspirin. So again, that's communication and keeping everything documented, keeping that paper trail. Off-duty healthcare providers and or lay people may provide emergency care prior to EMS arrival. Include the following information in your report. the bystander's procedures with specific notation that care was provided prior to your arrival. So if anybody did anything before you got there, you make sure you document who they are, their name, and what they did. Because again, you don't want nothing to reflect back on you that doesn't need to reflect back on you. So situations that require additional documentation. So there are special situations that require additional or different reporting procedures. Refusal of care. So refusal of care, we talked about yesterday. Refusal of care, the growth of malpractice lawsuits makes documentation of refusal of care very, very important. Competent adult patients have the right to refuse medical care or to consent to treatment. Know and understand a patient's rights. Learn applicable state laws about patient care and who has the right to refuse care. A decision to refuse care must be based on a patient's sufficient knowledge of their situation. Your most important job is to ensure the patient is fully informed about the current situation, the right to receive or refuse care, and consequences of refusal of care. The patient must be told in great detail and understand the potential consequences of refusing the necessary medical care, including the possibility of being unaligned. The information given to the patient... Excuse me. The information given to the patient must be conveyed in a language the person understands, documented on the PCR, witnessed by an observer. Initial and signed by the patient. So if you're getting a refusal, you want to make sure that they understand. Like if you speak English, that person speaks Spanish. You don't let them refuse. You got to make sure you have that language barrier broken somehow. Because again, you don't want to be misinterpreting that they're refusing something and actually telling you, hey, I want to go to the hospital. So make sure that person understands that what they're doing, what you guys are talking, what you're describing to them. and that they understand that they're refusing medical treatment. Document that they're refusing. Make sure it's a witness. So your partner or if there's anybody else on scene, make sure that they witness like, hey, you see this person is refusing to go to the hospital. And then you make sure the patient initials and signs that refusal form. OK, the refusal documentation should show the process you went through, how the process is documented and who witnessed the process. If you must transport a patient against their wishes, you must document your reason for transporting the patient against their will. by what means the patient was transported, if the patient was restrained, and if the patient was coached verbally or coerced. So again, like we talked about the other day, you can't be kidnapping folks. If somebody tell you they don't want to go to the hospital and they are in their right mind, they have a right to refuse. Now, if it's something very, very serious, like you do everything in your power to try to convince them to go to the hospital. But truth be told, like a person has the right if they just... If they just don't care anymore, like a person has the right to stay home and just let nature take its course. You cannot kidnap them. If they are in their right mind, if they're conscious alert, they're in their right mentation, and they're adamant like, hey, you're not taking me to the hospital. You run that up the chain. You talk to your supervisor. You see if they can convince them. Once you go through that whole process, you document how you went through this whole process and how much you tried to convince this person. And they still refuse to go to the hospital. You get them a sign and then you see what happens. But again, if you take them against their will, you will be charged with kidnapping. Always, always, always make sure you have a person's consent. And if you don't got it, they don't want to go. Make sure their refusal form is well documented and you get their signature. Unresponsive patients may be treated under implied consent. Paramedics EMT should be familiar with the individual state laws. So the age of consent, the care of minor laws, the emancipated minor laws, people with mental and cognitive impairments, including mental illness and the effects of drug or alcohol use. So you got to be familiar with the state laws when it comes to those things and transporting patients. If they if they have the right to refuse, if they don't under those special circumstances. And I know in my state, I'm pretty sure in most states, none of these people have the right to refuse. Confirm that every reasonable effort has been made to ensure the patient's welfare and best interests. If a patient has an obvious injury or medical condition that requires immediate medical attention and is refusing care, involve online medical control for further guidance and assistance. If you disagree with the refusal, a protocol or policy should be in place of what the next step should be. So additional steps may include contacting the supervisor, involving law enforcement, involving medical control. Again, you get a refusal with a high risk patient. You go through all the steps. You check all the boxes. You talk to everybody you need to talk to. Because again, if you let them sign that form and they. You know, they become unalive. You want to make sure like, hey, I tried to convince them. My supervisor tried to convince them. We call law enforcement. Law enforcement tried to convince them. They would not go. You make sure all that stuff is documented because you definitely don't want to run for unalive and suit against you because you're not going to win. I'm telling you, It is essential to have a witness present during the refusal process to ensure that the patient has sufficient knowledge of the situation to make an informed decision and witness the patient's refusal of care. Record all the following information on the patient care report, the observations of the witness and name and contact information of the witness. Attempt to attain a complete medical history and patient assessment when possible and practical, including a full set of baseline vitals. If a patient refuses assessment, document that in a PCR. So sometimes we'll be like, hey, I understand you don't want to go. Can we at least just check you out, get a set of vitals on you and go from there? Because a lot of times we'll get vitals and we'll show people, hey, this is what's going on. on a lot of times that'll change their mind very rarely they'll be like no i still don't care i don't want to go so again or they'll just outwire a few they'll tell you no i don't want to be checked out don't touch me and again they tell you don't touch them don't touch them Touch them when they tell you don't touch them. Salt and battery. Go into jail. It's a lot of risk out here. Even when you're just trying to do the right thing, there's a lot of risk for you to be on the wrong side of the law. So again, always make sure you document everything and you're respecting your patient's wishes. Always evaluate the patient's mental status. The mental status may be considered impaired if the person is not oriented to person, place, or time. So if somebody can't tell you who they are, where they are, or when it is, you consider that person to not be mentally stable. And then you can kind of treat them under implied consent because you can see, hey, this person may not be in their right mind. And then if they were and they might be in their right mind, they would want me to treat and transport them. So again... Just walk in that line. You have to make sure you do your evaluation. So if you're transporting that person under this, under the basis that this person is not mentally fit to make their right decisions right now, you got to document why you feel that way. And again, that's where you do your, your mental status check. So you, use person place of time so what we'll do is one of the first things we do is like hey what's your name what city are you in right now what year is it and then a fourth one that we always used to use is who's the president but for obvious reasons we don't use that one no more um over the last few years it was just too much so what i started using i'll ask somebody how many quarters are in a dollar and once you answer them four questions you alert you're oriented we're good to go But yeah, that was like the last four years, just like asking that question. And you'd be like, won't anyone go down that road? Impairment may be a result of injury, a medical condition such as electrolyte imbalance or hypoglycemia, mental illness, drug or alcohol use. So all those are all those are things that can lead to impairment. And again, if someone's impaired, you can treat them under implied consent. If they were in their right state of mind, they would want you to treat them. Always politely explain to patients that they have the right to change their minds and call EMS again later. So again, because their patient refused at that moment, you go through all those steps, you get a refusal form. They can still call you back an hour later and be like, hey, I changed my mind. Take me to the hospital. You get your behind over there, you take it to the hospital. Document the care you intended to provide if the patient had not refused and document whose care you left the patient in. So, hey. If they got somebody with them when you're refusing, you document who that person was. And again, when you're doing your documentation, you write, hey, this is what I wanted to do for the patient and the patient refused. So, again, always, always, always document everything. Cover your butt. Propose all potential methods of care, including alternative options that may not be your first choice. For example, a patient is going to be driven to the hospital by a family member rather than being transported via ambulance. Always encourage transport by ambulance because patient conditions can change at any time. So again, if they won't go with you, try to convince them to be like, hey, will you let one of your family members take you to the hospital? If they're just adamant about refusing to go with you, go to the hospital. And I get it because a lot of people, they're just thinking about the money. They're thinking about, I can't afford to get in this ambulance, right? now but you want them to get to the hospital because they're obviously having a a medical event and having something that they need to get seen for right now so you can't convince them to go with you and they just refuse adamantly by going with you say hey will you let your husband take you with it Will you let your wife take you? Will you let your son take you? Will you let your daughter take you? Will you let anybody take you to the hospital? I will help you go from the house and get in their car as long as you go to the hospital. So you want to be presenting those options as well. It's obviously better if they go with you because you can monitor them if anything goes bad. You know, you can be there, but at the same time, if they just refuse to go with you, at least you're presenting them with that option and you're still trying to get them to the hospital. And again, you would document that. Patient refused to be transported by ambulance. However. was able to convince patient to go to hospital POV, which is personal vehicle. Patients may agree to be transported but refuse a particular procedure and refusal of specific procedures should be handled as if a refusal of care and should include the following the explanation of associated risks and complications of refusal signature by the patient acknowledging refusal of a portion of care the witnesses signature and complete and accurate documentation so again you can um You be working with someone and they be like, hey, I got to start an IV and they be like, no, you not start an IV on me. I'll wait till I get to the hospital. Document it. I'm like, all right, you don't want me to do it. Let me document that. If you don't let me start this IV, I can't give you the medicines that you might need in case of an emergency. Do you understand this? Yes, I understand. Cool. Sign here. Keep it moving. As long as you got everything documented, Workplace injuries and illness. So the Occupational Safety and Health Administration or OSHA guidelines require that workplace injuries must be logged. Institutions may have their own forms and requirements for documenting workplace injuries. Minor injuries requiring basic first aid do not require an OSHA record, but documentation may be required by the company. Document what precautions were taken and what protective equipment was being worn by the person involved. Reporting regulations vary from state to state, so be familiar with the state's requirements. Paramedics and EMTs may also perform medical monitoring for hazardous material teams, respond to other employee workplace injuries, and experience on-the-job injuries or illnesses. So special circumstances, some situations that may require specialized forms per your state or local agency include multiple casualty incidents. So like really big, like multiple casualty incidents. So like I.E. school pew pews, no big. Basically anything that got a whole lot of people that need to go to the hospital, basically. Occupational exposures, abuse and neglect cases, a physician's arrival or presence on the scene of a call. During an MCI, documentation often occurs initially on triage tags. So become familiar with what a triage tag is. And it is important for each emergency responder completing the tags to supply as much information as possible on them. Occupational exposures report should be completed if a barrier device fails or failed to offer enough protection from body fluids or other toxins or infectious agents. So if you ever get exposed to anybody whether it's a blood or fluids Any kind of exposures, you want to make sure you document it and have a report. That way, you know, God forbid something happens to you as a result of being exposed and you need treatment. You want to make sure like, hey, y'all covering this because I was working while this happened. All right. So document everything. Additional specialized documentation may be needed for alleged neglect or abuse calls. So supply as much detail as possible about the circumstances and document your findings objectively. Document the use of all mutual aid services such as helicopters, specialized rescue teams, and other agencies that respond to the calls. You document all unusual occurrences including securing the patient with restraining devices, having to summon additional crew or specialty vehicle to lift the heavy patient, extended scene time for a prolonged extrication, or severe weather condition delaying responses. Those are all examples of things you need to document that might be unusual during that call. Always follow the policy of your medical director. And just so you know, paramedics are held responsible for security and accountability of controlled substances. So a lot of things, medicines we get on the truck, they are considered controlled substances. So we keep a record of what we have. So if anything goes missing, we know who was the last to sign and say, this is what we had. So between when you had it and I had it, this went missing. So when I signed it, it was there. So I don't know what happened. But when I signed it and my witness signed it, we saw it. So you need to find out what happened. happen. So yeah, you keep a record of everything. Everything needs to be recorded and documented. And double signatures, again, you always have a witness when you're dealing with controlled substances. You check, use, discarded, and replaced. All those things have to be documented when dealing with controlled substances. So, for example, you document how much you used, how much you threw away, the patient who you gave it to, the date and time it was administered, and who administered it. All that stuff got to be documented. They do not play about controlled substances. So you make sure you documented everything. So we're talking about completing the patient care report. So the patient care report contains check boxes and a narrative portion. The narrative portion of the patient care report should be detailed, written in a format accepted by your agency, accurate and complete and specific. Some services attack a copy of the readings to their documentations. Each of the following should be documented into narrative section. The consultations, the orders requested or received from medical control, refusal situations in which medical control was consulted. Do not just write something like see refusal on back. Don't do that. Again, be detailed and specific about everything that happens during a call. There are many methods for narrative documentation. EMS agencies and medical directors may prefer a specific method, so know whatever your agency likes to do, make sure you're writing in that method. Some writing styles for narratives like chronological order, which is basically telling the story in a story format from the time you were dispatched to the time the call's in. You have a SOAP method, which is basically a method that divides your patient care report into four different sections. You have the subjective information, the objective information, the assessment, and then the plan for treatment. Regardless of the style of narrative report, use the same reporting method consistently. So don't switch how you do reports. Once you find a way that you like to write your reports, stick to that way. Keep it nice and consistent. Don't switch. Don't be back and forth. I use the SOAP method personally for where I work. Pertinent negatives should always be documented when writing an EMS report. So a pertinent negative is a record of a negative finding that warrants no care of intervention but indicate a thorough examination of history was performed. So for example, if I'm running a call a pertinent negative would be the patient denies having chest pain. The patient denies having shortness of breath. The patient denies loss of consciousness. So I've established that I've examined this patient. They said they did not lose consciousness or they were never unconscious at any point in time. is not hurting. I heard from the patient's mouth, they said their chest is not hurting, so I'm not going down that route. And then the patient is not complaining of any shortness of breath. So when I hand you this patient, based on my report, I handed you this patient, they had no chest pain, they were breathing okay, and they was in a right state of mind. All right, whatever happens after that, it's on you. But when I had them, it was documented. And again, sign sealed and delivered. Spoken accounts may include statements of the patient's behavior, the MOI, the safety-related information such as the use of weapons, and the following may also be useful to list in the narrative section. So you always want to make sure disposition is valuable so the patient has like wallet, their watch, any kind of jewelry on them. You want to make sure that you document that and you make sure that patient leaves from your care to that next person's care with all their stuff and you document it in that patient care report. Like, hey, yep, when I turned them over. I gave the patients first, the wallet and all that other stuff. Because again, for whatever reason, stuff likes to go missing in the hospital and you don't want it to come back on you. So you document all that stuff like, hey, when they was with me, when I transferred and handed them over, I handed them over with everything. I didn't have none of their stuff. I make sure they had all their possessions. You and you will be you will be surprised how much stuff goes missing at the hospitals. All right. So elements of a properly written report. Documentation accuracy depends on all the information being complete and precise. The incident times, the narrative information, and all the check boxes are complete. Complete all sections of the PCR, even if a section was not applicable to a call. So leaving the boxes blank may raise questions in the completeness of the report. So if you have a section that if you have a section of your report that you didn't do, just put on not completed or not applicable. Put something in there, but don't leave it blank, because if you leave it blank, it's going to be assumed that you didn't do it at all. Handwritten report should be legible, written in ink, neat and easy to read. Place all completed reports in a secure location that protects the patient's privacy agreed upon by you and your partner. A PCR needs to be completed in a timely manner, so make sure you get all your reports done as soon as possible. Some type of written record must always be left with the patient. So a drop report or transfer report is a single page abbreviated form used as a memory aid during an EMS call. Leave a copy of that drop report or transfer report with the nurse or physician. All PCR should be free of the following. any kind of special jargon, slang, or personal opinions. Leave that stuff out of your reports. Again, your report is factual, based upon the facts and facts of your objective information and the subjective information. Stick to the facts. Again, that is a legal document. Don't be putting your opinions, don't be putting your emojis and your short form writing, your text writing. I know we're in a new generation that's coming up, so a lot of us didn't really pay that much attention. in English class, but you got the ways to properly write. You need to bring those to the EMS field. Don't be, I'm telling you, you'd be surprised, man. I'm 36 years old and we get a lot of guys that are like in their twenties that come and start with the department. And you could tell like they're young because they'll do the report and you'll catch them. Like when you review their report, you'll catch them, like do some short form stuff. Like they texted somebody. It's like, Hey man, this ain't going to fly. You got to write out, we write out your words in the adult world. So just keep that in mind. Be certain that your documentation is not libelous. Remember libel. Libel is writing the false statements that could be harmful to a person's current or future reputation. So be certain that your documentation is not libelous. All right. Only true and accurate statements should be documented. So be certain that your documentation is not libelous. All right. Only true and accurate statements should be documented. Review your reports before submitting them to the receiving medical facility and your supervisor. So you review your reports for completeness, accuracy, grammar, spelling, and proper use of medical terminology and abbreviations. All written reports reflect on the paramedic. Consequences of poor documentation. So inappropriate, inaccurate, and insufficient documentation can adversely affect the quality of care received by patients at the arrival at the hospital. Document what the patient or family member tells you and your findings from examining the patient will enhance the quality of care. Remember to document the specific time a suspected stroke patient was last seen normal by family members, for example. Important to the window of time for treatment using fiber. So the reason why it's so important, like some, for example, like documenting when the last time a patient was seen normal that suffered from a stroke. So when you have a stroke, again, that's something that we'll get into a little bit later. But right now, just going over briefly, when you have a stroke, what happens is you get a clot up in your brain. And what they do for the clot is they give you something called fibroanalytics, basically like a clot buster. So there's a certain amount of time, like a window, that you are able to receive that treatment. So they were last seen normal over 24 hours ago. they can no longer receive the clock buster because it can have a negative impact on whatever their stroke symptoms. OK, so that's an example of why it is important to ask questions like that and make sure you document everything and all the information that the family is giving you. Poor documentation skills can affect the paramedic reputation. There are significant legal implications of documentation. Poorly written, inaccurate, or ineligible reports might lead a judge or jury to decide in favor of the plaintiff. A lawyer may decide not to pursue a case when the documentation reveals a correctly written and well-documented report. report. So if your reports is good and these people out here just trying to get some money, they're just trying to sue you off the strength of just trying to, you know, see if they can get over. If your report is spot on and they can't poke no holes in it, a lot of times don't even want to mess with you. So again, like I told you guys, I've been... been deposed before. I've been reached out to like, hey, we want to do a deposition based upon this case. And they don't look at the report I wrote and they just tell me, you know, we don't need you. Like, never mind. And again, that's just because I make sure everything, you can't poke no holes in it. You can't poke no holes in it. Case closed, case dismissed, man. So that's why documentation is very, very important. Errors and falsifications. So at times it is necessary to revive or correct a patient care report. If a revision or correction must be made to report, note the date and time of that revised report. Include the purpose for writing the revision or making the correction. and never discard or destroy the original patient care report. So if you got to make any corrections, you go through those steps, but don't throw away that own report. Because again, you're going to give off the impression you're trying to destroy evidence and you're trying to hide something. If you got to make a correctional... a revision, you just put it and attach it on top of the previous report that you did. And only the person who wrote the original report can make any revisions. So you can't have a friend say, hey man, I'm about to get off shift. Can you correct this for me? That ain't gonna fly. If you need to make a revision to your report, you're the only person that can do it. Routine administrative report handling and reviews are necessary for entering information in the computer databases, billing for services, and quality assurance monitoring. Administrative activities should never involve altering or rewriting a report or portions of it. So if they don't like what they see in the report, your administrator or your supervisor, they'll kick it back down to you and be like, hey, you need to fix this. That type of deal. Do not erase information, scribble through errors, use correction fluid or correction tape. Remember the PCR is a legal document. Most electronic reporting systems will allow for amendments but will prevent erasure in a completed document. Refer to the system's direction as to how to make an amendment to the original document. If there is no way to electronically change the report, follow the same procedures for a written document after printing the report. Addendums may be needed to add forgotten important information to a report and write statements of events for matters related to quality assurance or risk management and answer any complaints. Addendums should include a note that the addendum was added to the original report, reason for the late entry, date of entry and time of entry, and also signature of the author. Loss reports pose huge legal implications, so all paramedics are responsible for ensuring their reports are completed and turned in as required by policy or procedure. Do not keep copies of these reports. Trying to recreate PCRs is irresponsible and possibly illegal. Ain't no possibly, it's illegal. Record keeping may be a legal requirement in your state. and there may be a specific time requirement for submission of these reports. When you're documenting incident times, accurate timekeeping is essential to all EMS operations. So the role of timekeeping falls to dispatchers. So dispatchers are your timekeepers. They they keep everything in a time. Every time stamp the dispatch keeps. They put it in your CAD system so you can update it to your report. So you don't have to worry about that on seeing your dispatchers usually keeping your times, whether that's the time you dispatch, the time you arrive, the time you start transporting to the hospital, the time you arrive to the hospital. Dispatch keeps keeps track of all of that for you. So that's one less thing you have to worry about. Just make sure you include it in your report. You always include that into your report. and you compare times with dispatchers to ensure accuracy and proper timekeeping that yours and yours dispatchers clocks are synchronized discrepancies can lead to controversies controversies in the courtrooms so again always make sure you and your dispatch is on the same page when it comes to those times so following incident times are crucial to track okay you want to make sure you track the time of the call time of dispatch time of arrival at the scene time with the patient Time of any medication administration you do. Time of any medical interventions that you do. Time of departure from the scene. Time of arrival at the medical facility. Time you transferred to care. And your time back in service. Times are kept in military units to avoid confusion. So we operate on 2400 clock in EMS. 2400 hour clock in EMS. All right, guys. That's chapter six. It's documentation.

It is a legal record for the call, so all patient care reports are legal documents. That's why I was talking earlier this week, you know, about how critical your reports are. That report is considered a legal document. So it is basically admissible in court for evidence.

So you have to make sure you are doing the right thing when you write those reports and always being professional. It becomes part of the patient's medical record and emergency department chart. It helps guide future patients and quality assurance.

An EMS professional needs to know what constitute a PCR. what information must be included, who might read the PCR, when the PCR must be completed, and what terminology may be used. Information can be objective or subjective. So objective information is measurable signs that you observe and record, i.e. like pulse rate, respiratory rate, blood pressure.

So basically all your vital signs, that's objective information. Anything that you can measure as fact. So your vital signs are basically objective information. Subjective information is information that is told to you, but that cannot be seen. So like symptoms that a patient has described, a degree of pain, nausea, how they're feeling, like all that stuff is considered subjective information.

All right. So remember there's two types of information is objective and subjective. information. Know the difference between objective information and subjective information. The required information for the PCR, you have to have both objective information, subjective information, and the details of the patient's care.

PCR must be complete, accurate, and legible. It can be the basis of a defense and legal proceedings. Like I told you guys, it's a legal document, so it has to be legible.

That's why 99% of, I think, all EMS providers, they got tablets. So everything is typed out because you all know people handwriting is not the best. So most EMS systems, everybody has a tablet that they can do their reports on. This PCR also facilitates quality and continuity of care and is used to bill insurance.

So the report is sent to the insurance agencies, whatever is in that report, so they make sure everything lines up between the hospital and EMS so they can bill for the appropriate. things. They don't want to have disconnects. So a lot of times when people get their bills back from the hospital, depending on what happened in the ambulance, as opposed to what happened in the hospital, you'll get discrepancies. And you know, insurance companies, they look for any reason to deny your claim.

So you always want to make sure everybody's on the same page and everything lines up accordingly. So legal implications of the PCR. So reports may include subjective statements from the patient, but cannot include any personal bias or opinions a paramedic may have regarding the patient. Again, always be professional.

Leave your personal feelings about whatever you're dealing with or your thoughts about the patient. Leave that out. It's always professional at all times.

All right. PCRs that are poorly written or inappropriately documented could have adverse implications for patient care and for a paramedic's career. Emissions or errors could lead to further errors in care of the patient.

Improper and inadequate reports can result in litigation, job loss or demotion, and poor reputation for you as an EMS provider. So again, your reports are... or key, man, whatever you put on that report, that reflects that it's a reflection of you. So always make sure those reports, again, accurate, clear, professional, because again, it is a reflection of you.

All right. And again, it can be used against you in litigation. Paramedics have been found guilty of neglect based on the failure to perform patient exams and submit completed paperwork. So like we was talking about in our discussion board video a few days ago, the paramedics put that there was no patient found. So they documented that in a legal document.

So what they were stating was, so basically that document says, hey, there was no patient found. They're putting that on pen to paper and tablet or whatever, stating that as facts. So now when that's presented in court, This is what happened.

The woman's deteriorated and she ended up becoming unalive. You say you've never seen her. You say there was no patient care.

Patient wasn't found. However, the family is stating that you guys did show up. You didn't do anything for and she drove herself to the hospital.

So, again, that patient report, you make sure you document everything factually and accurately, because, again, when it come to when it come to court, when it come to putting it. stuff in front of the stand and it's your word your word don't matter no more whatever is in that report so make sure you are always accurate and being truthful in your patient care reports reports should be complete well written legible professional and the sole source of information about the call may be used in legal proceeding proceedings years after the call and it may be your only defense against a complaint about a call use proper spelling grammar and accurate terminology sloppy documentation implies sloppy care The Health Insurance Portability Act, or HIPAA, has ramifications related to patient care reporting. So again, guys, as it pertains to what I just talked about, so just for example, I've been in depositions. Depositions don't happen like right away, like immediately after a call has happened.

I've had depositions that I've had to go to. A lawyer will call me and the call would have been from two or three years ago. And like, let's just be honest. Can you really remember two or three years ago in very like detail? Like certain things, yes.

But like I see so many patients like, do you really think I'm going to remember something from three years ago with great, great excruciating detail? Obviously not. All I have is whatever is in that patient care report.

That is my defense. So if I was sloppy with that report or. I had any inaccurate information or what I'm remembering doesn't line up with what's in that report.

They're going to go off that report. They're going to go off whatever you wrote at the time. So whatever you wrote at the time, that's that's that's what it is. That's that's gospel. So make sure, again, be truthful, be honest, be factual, be professional whenever you're doing these patient reports.

So purposes of documentation. All right. So purposes of documentation. So you want to have a continuity of care.

So the PCR serves as a record of the patient's condition upon your arrival to the scene, the care that was provided, any changes in the patient's condition in route, condition on arrival at the hospital. The PCR should be accurate and clear to ensure better patient care at the hospital. The minimum requirements in billing PCR writing must be accurate and complete for billing and administration care at the hospital. The minimum requirements in billing, PCR writing must be accurate and complete for billing and administration. For complete and accurate revenue recovery, you must ensure procedures performed are documented, medical necessity signatures are obtained.

Reason the patient needed to be transported by ambulance is documented. Inaccurate or incomplete documentation delays the billing process. Your agency may require additional billing paperwork.

EMS research. So researchers use the information collected by EMS providers to justify innovative life-saving techniques. Many states now require EMS agencies to submit data to their state EMS office to verify call volumes and skills used, including the number of calls to which an agency responds to, the types of calls, the care that's provided, patient outcomes, patient outcomes, and also patient demographics.

Patient care data collection can improve the EMS system as a whole. The National Emergency Medical Services Information System stores standardized EMS data from each individual state. This central, excuse me, excuse me. This central repository collects research nationwide to assist in future curriculum development.

The goal of NMESIS, which is the National Emergency Medical Services Information System, is to define EMS care by collecting data to improve patient care, identifying equipment needs, and defining a standard of care across the nation. Incident Review and Quality Assurance. So occasional PCRs may be requested for medical audits and other educational activities. So run reviews are sessions where peers or other medical professionals review PCRs for adherence to local protocols, quality assurance and quality monitoring. Always accurately document skills attempted and performed during patient care.

So even if you perform an intervention and it's unsuccessful, you have to document that. I document everything that you do. So let's say I'm starting an IV on a patient. For every IV I start, if it's successful or unsuccessful, I have to document that. So if I start an IV and I don't get it, I have to document that as, hey, IV started, attempt number one, unsuccessful.

And then if you have to start, try another attempt. Again, IV started, attempt number two, successful, for example. Again, document everything.

So most EMS reporting is done electronically. Electronic documentation has many benefits. It can be shared easily between the facility and personnel involved in the patient's care.

It improves continuity and efficiency of care. It can be shared among state and national databases which improves national data collection. Some services have developed check boxes and drop down menus instead of instead of narrative sections. So it makes it easier and more efficient to do these reports.

They upload a lot of information into these programs. So now we're just doing a lot of drag and drop or just drag and click, just drag and click. That way we get through these reports faster. We can get back into service faster so we can serve the next patient or be ready for the next call.

The only problem with the checkbox format is it can present with a risk of errors. So that's why you always double checking the things that you check. Always double check what you're looking at.

Don't just be starting to get automatic or robotic with it because you do so many because then you can make errors. And again, whatever is in that report is what's used against you if it ever gets bought up to court. Most agencies are shifting away from paper reporting. Paper reporting is a duplication of the work.

If you're doing it electronically, you shouldn't do paper reporting as well. Paper requires storage. So again, you're getting all these paper documents, you got to store them somewhere.

So obviously, you want to save space to keep everything electronic. Modern data systems incorporate data from various sources such as multiple facilities to improve patient care. So the result is one comprehensive record for the patient and electronic documentation systems should be Nemesis compliant. So whatever system that.

your company is working in when you get into EMS, it all has to be nemesis compliant because again, it has to be able to be seen nationally if need be. So again, make sure that you guys, when you document and you're doing... these reports everything is accurate everything is professional i keep repeating it guys because it's it's so important it's so important man you don't want to be in no legal trouble for some paperwork or paperwork error that's that's a stupid reason to be uh that's a stupid reason to get involved or be in trouble legally documentation for every ems call So every EMS call requires documentation, regardless if you see a patient, the patient refuses to go to the hospital, a false alarm, everything needs to be documented.

Any call you get, make sure you document what happened on that call. Even if we get dispatched in a 911 call and they cancel us en route, that's a patient report. We have to do a report.

So even if it's something as simple as canceled en route, that keep everything documented, every call documented. The minimum data set is the mandatory clinical assessment standard information that must be documented on every call. It's set by Medicare and Medicaid.

It's per the National Highway Traffic Safety Administration and it's for the purpose of the national data system. The minimum data set is divided into run data and patient data. So run data consists of incident times, locations, responding units, crew member names of the working of those working at the incidents. So again, the run number, the run data is basically the incident times, the locations, the responding units, and the crew members, whoever was working on the scene.

The patient data includes basic patient information collected on the patient care report, such as the chief complaint, the level of consciousness, the vital signs, the assessments, and the patient demographics. The patient care report should document objective observations of the scene, i.e. living conditions, the mechanism of injury, other areas of concern, etc. Things of that nature. The treatments provided, the effects of those treatments, and changes in patients conditions during the emergency call.

Depending on the type of transport, service treatments may need to be differentiated between scheduled and unexpected. An example of a scheduled treatment is a transfer report. Unexpected treatments result from changes in a patient condition. So transfer of care.

When you're transferring care, it is important to document in whose care the patient was left to avoid allegations of abandonment. So when we talked about abandonment the other day, remember, you don't leave that patient until you've turned that patient over to a higher level of care. So if you've taken a patient to the hospital, you don't leave that patient until a nurse or a doctor takes responsibility of that patient and you make sure they sign that they took responsibility of that patient. And if you don't get a signature, let's say, for example, you take that patient over, you hand them to a nurse, y'all have a conversation, you give that person a rundown, you don't get that signature.

Let's say that patient deteriorates or goes down, or the nurse does something wrong and something happens to that patient and that patient has a negative outcome. If that nurse really wanted to or she wanted to stay out of trouble, she could just say, I never touched this patient. When I got here, nobody gave me patient care report.

I didn't know anything. And now you don't have that lady's signature that you talked with her and told her everything that was going on. Now it falls all the way back on you. So again, always make sure when you're dealing with the hospital, I don't care if you know the nurses or you know you got good relationships with these people. Hey, by the way, I need you to sign.

Always cover your butt. I need you to sign. Give me your signature, please. Care prior to arrival. More emergency dispatch centers are shifting to a system called Emergency Medical Dispatch, or EMD.

EMD allows the dispatcher to select the appropriate units to respond and provide directions to the caller for medical care and medication administration over the phone. When you encounter an EMD, it is important to obtain information from the patient or caller as to what care has been provided prior to your arrival, and document your findings. An example of what an EMD center might do is to prescribe aspirin to a caller experiencing chest pain. So an example of correct documentation of this will ensure the patient does not receive the same medication again. So you want to make sure that if your dispatcher gives any pre-arrival instructions, like, for example, if somebody's experiencing chest pain, the dispatcher will be like, well, do you have any aspirin at the house that you can take?

And the patient's like, yeah, I have some. And the dispatcher will tell them, do you want to take 324 milligrams of baby aspirin or aspirin? The person takes that before you get there.

Now, when you get there, you want to make sure that person and dispatcher communicate. to you like, hey, that person has already taken 324 milligrams of aspirin. So I know as a provider, they already have aspirin on board. I don't need to give them an additional dose of aspirin.

So again, that's communication and keeping everything documented, keeping that paper trail. Off-duty healthcare providers and or lay people may provide emergency care prior to EMS arrival. Include the following information in your report. the bystander's procedures with specific notation that care was provided prior to your arrival. So if anybody did anything before you got there, you make sure you document who they are, their name, and what they did.

Because again, you don't want nothing to reflect back on you that doesn't need to reflect back on you. So situations that require additional documentation. So there are special situations that require additional or different reporting procedures. Refusal of care.

So refusal of care, we talked about yesterday. Refusal of care, the growth of malpractice lawsuits makes documentation of refusal of care very, very important. Competent adult patients have the right to refuse medical care or to consent to treatment. Know and understand a patient's rights. Learn applicable state laws about patient care and who has the right to refuse care.

A decision to refuse care must be based on a patient's sufficient knowledge of their situation. Your most important job is to ensure the patient is fully informed about the current situation, the right to receive or refuse care, and consequences of refusal of care. The patient must be told in great detail and understand the potential consequences of refusing the necessary medical care, including the possibility of being unaligned.

The information given to the patient... Excuse me. The information given to the patient must be conveyed in a language the person understands, documented on the PCR, witnessed by an observer. Initial and signed by the patient.

So if you're getting a refusal, you want to make sure that they understand. Like if you speak English, that person speaks Spanish. You don't let them refuse. You got to make sure you have that language barrier broken somehow.

Because again, you don't want to be misinterpreting that they're refusing something and actually telling you, hey, I want to go to the hospital. So make sure that person understands that what they're doing, what you guys are talking, what you're describing to them. and that they understand that they're refusing medical treatment. Document that they're refusing.

Make sure it's a witness. So your partner or if there's anybody else on scene, make sure that they witness like, hey, you see this person is refusing to go to the hospital. And then you make sure the patient initials and signs that refusal form.

OK, the refusal documentation should show the process you went through, how the process is documented and who witnessed the process. If you must transport a patient against their wishes, you must document your reason for transporting the patient against their will. by what means the patient was transported, if the patient was restrained, and if the patient was coached verbally or coerced. So again, like we talked about the other day, you can't be kidnapping folks. If somebody tell you they don't want to go to the hospital and they are in their right mind, they have a right to refuse.

Now, if it's something very, very serious, like you do everything in your power to try to convince them to go to the hospital. But truth be told, like a person has the right if they just... If they just don't care anymore, like a person has the right to stay home and just let nature take its course. You cannot kidnap them.

If they are in their right mind, if they're conscious alert, they're in their right mentation, and they're adamant like, hey, you're not taking me to the hospital. You run that up the chain. You talk to your supervisor. You see if they can convince them. Once you go through that whole process, you document how you went through this whole process and how much you tried to convince this person.

And they still refuse to go to the hospital. You get them a sign and then you see what happens. But again, if you take them against their will, you will be charged with kidnapping. Always, always, always make sure you have a person's consent.

And if you don't got it, they don't want to go. Make sure their refusal form is well documented and you get their signature. Unresponsive patients may be treated under implied consent.

Paramedics EMT should be familiar with the individual state laws. So the age of consent, the care of minor laws, the emancipated minor laws, people with mental and cognitive impairments, including mental illness and the effects of drug or alcohol use. So you got to be familiar with the state laws when it comes to those things and transporting patients.

If they if they have the right to refuse, if they don't under those special circumstances. And I know in my state, I'm pretty sure in most states, none of these people have the right to refuse. Confirm that every reasonable effort has been made to ensure the patient's welfare and best interests.

If a patient has an obvious injury or medical condition that requires immediate medical attention and is refusing care, involve online medical control for further guidance and assistance. If you disagree with the refusal, a protocol or policy should be in place of what the next step should be. So additional steps may include contacting the supervisor, involving law enforcement, involving medical control.

Again, you get a refusal with a high risk patient. You go through all the steps. You check all the boxes. You talk to everybody you need to talk to. Because again, if you let them sign that form and they.

You know, they become unalive. You want to make sure like, hey, I tried to convince them. My supervisor tried to convince them. We call law enforcement. Law enforcement tried to convince them.

They would not go. You make sure all that stuff is documented because you definitely don't want to run for unalive and suit against you because you're not going to win. I'm telling you, It is essential to have a witness present during the refusal process to ensure that the patient has sufficient knowledge of the situation to make an informed decision and witness the patient's refusal of care.

Record all the following information on the patient care report, the observations of the witness and name and contact information of the witness. Attempt to attain a complete medical history and patient assessment when possible and practical, including a full set of baseline vitals. If a patient refuses assessment, document that in a PCR. So sometimes we'll be like, hey, I understand you don't want to go.

Can we at least just check you out, get a set of vitals on you and go from there? Because a lot of times we'll get vitals and we'll show people, hey, this is what's going on. on a lot of times that'll change their mind very rarely they'll be like no i still don't care i don't want to go so again or they'll just outwire a few they'll tell you no i don't want to be checked out don't touch me and again they tell you don't touch them don't touch them Touch them when they tell you don't touch them. Salt and battery. Go into jail.

It's a lot of risk out here. Even when you're just trying to do the right thing, there's a lot of risk for you to be on the wrong side of the law. So again, always make sure you document everything and you're respecting your patient's wishes. Always evaluate the patient's mental status.

The mental status may be considered impaired if the person is not oriented to person, place, or time. So if somebody can't tell you who they are, where they are, or when it is, you consider that person to not be mentally stable. And then you can kind of treat them under implied consent because you can see, hey, this person may not be in their right mind.

And then if they were and they might be in their right mind, they would want me to treat and transport them. So again... Just walk in that line. You have to make sure you do your evaluation.

So if you're transporting that person under this, under the basis that this person is not mentally fit to make their right decisions right now, you got to document why you feel that way. And again, that's where you do your, your mental status check. So you, use person place of time so what we'll do is one of the first things we do is like hey what's your name what city are you in right now what year is it and then a fourth one that we always used to use is who's the president but for obvious reasons we don't use that one no more um over the last few years it was just too much so what i started using i'll ask somebody how many quarters are in a dollar and once you answer them four questions you alert you're oriented we're good to go But yeah, that was like the last four years, just like asking that question. And you'd be like, won't anyone go down that road?

Impairment may be a result of injury, a medical condition such as electrolyte imbalance or hypoglycemia, mental illness, drug or alcohol use. So all those are all those are things that can lead to impairment. And again, if someone's impaired, you can treat them under implied consent. If they were in their right state of mind, they would want you to treat them. Always politely explain to patients that they have the right to change their minds and call EMS again later.

So again, because their patient refused at that moment, you go through all those steps, you get a refusal form. They can still call you back an hour later and be like, hey, I changed my mind. Take me to the hospital. You get your behind over there, you take it to the hospital.

Document the care you intended to provide if the patient had not refused and document whose care you left the patient in. So, hey. If they got somebody with them when you're refusing, you document who that person was. And again, when you're doing your documentation, you write, hey, this is what I wanted to do for the patient and the patient refused.

So, again, always, always, always document everything. Cover your butt. Propose all potential methods of care, including alternative options that may not be your first choice. For example, a patient is going to be driven to the hospital by a family member rather than being transported via ambulance. Always encourage transport by ambulance because patient conditions can change at any time.

So again, if they won't go with you, try to convince them to be like, hey, will you let one of your family members take you to the hospital? If they're just adamant about refusing to go with you, go to the hospital. And I get it because a lot of people, they're just thinking about the money. They're thinking about, I can't afford to get in this ambulance, right?

now but you want them to get to the hospital because they're obviously having a a medical event and having something that they need to get seen for right now so you can't convince them to go with you and they just refuse adamantly by going with you say hey will you let your husband take you with it Will you let your wife take you? Will you let your son take you? Will you let your daughter take you? Will you let anybody take you to the hospital?

I will help you go from the house and get in their car as long as you go to the hospital. So you want to be presenting those options as well. It's obviously better if they go with you because you can monitor them if anything goes bad.

You know, you can be there, but at the same time, if they just refuse to go with you, at least you're presenting them with that option and you're still trying to get them to the hospital. And again, you would document that. Patient refused to be transported by ambulance. However. was able to convince patient to go to hospital POV, which is personal vehicle.

Patients may agree to be transported but refuse a particular procedure and refusal of specific procedures should be handled as if a refusal of care and should include the following the explanation of associated risks and complications of refusal signature by the patient acknowledging refusal of a portion of care the witnesses signature and complete and accurate documentation so again you can um You be working with someone and they be like, hey, I got to start an IV and they be like, no, you not start an IV on me. I'll wait till I get to the hospital. Document it. I'm like, all right, you don't want me to do it. Let me document that.

If you don't let me start this IV, I can't give you the medicines that you might need in case of an emergency. Do you understand this? Yes, I understand. Cool.

Sign here. Keep it moving. As long as you got everything documented, Workplace injuries and illness.

So the Occupational Safety and Health Administration or OSHA guidelines require that workplace injuries must be logged. Institutions may have their own forms and requirements for documenting workplace injuries. Minor injuries requiring basic first aid do not require an OSHA record, but documentation may be required by the company. Document what precautions were taken and what protective equipment was being worn by the person involved.

Reporting regulations vary from state to state, so be familiar with the state's requirements. Paramedics and EMTs may also perform medical monitoring for hazardous material teams, respond to other employee workplace injuries, and experience on-the-job injuries or illnesses. So special circumstances, some situations that may require specialized forms per your state or local agency include multiple casualty incidents.

So like really big, like multiple casualty incidents. So like I.E. school pew pews, no big. Basically anything that got a whole lot of people that need to go to the hospital, basically.

Occupational exposures, abuse and neglect cases, a physician's arrival or presence on the scene of a call. During an MCI, documentation often occurs initially on triage tags. So become familiar with what a triage tag is.

And it is important for each emergency responder completing the tags to supply as much information as possible on them. Occupational exposures report should be completed if a barrier device fails or failed to offer enough protection from body fluids or other toxins or infectious agents. So if you ever get exposed to anybody whether it's a blood or fluids Any kind of exposures, you want to make sure you document it and have a report.

That way, you know, God forbid something happens to you as a result of being exposed and you need treatment. You want to make sure like, hey, y'all covering this because I was working while this happened. All right.

So document everything. Additional specialized documentation may be needed for alleged neglect or abuse calls. So supply as much detail as possible about the circumstances and document your findings objectively. Document the use of all mutual aid services such as helicopters, specialized rescue teams, and other agencies that respond to the calls. You document all unusual occurrences including securing the patient with restraining devices, having to summon additional crew or specialty vehicle to lift the heavy patient, extended scene time for a prolonged extrication, or severe weather condition delaying responses.

Those are all examples of things you need to document that might be unusual during that call. Always follow the policy of your medical director. And just so you know, paramedics are held responsible for security and accountability of controlled substances. So a lot of things, medicines we get on the truck, they are considered controlled substances.

So we keep a record of what we have. So if anything goes missing, we know who was the last to sign and say, this is what we had. So between when you had it and I had it, this went missing. So when I signed it, it was there.

So I don't know what happened. But when I signed it and my witness signed it, we saw it. So you need to find out what happened.

happen. So yeah, you keep a record of everything. Everything needs to be recorded and documented. And double signatures, again, you always have a witness when you're dealing with controlled substances.

You check, use, discarded, and replaced. All those things have to be documented when dealing with controlled substances. So, for example, you document how much you used, how much you threw away, the patient who you gave it to, the date and time it was administered, and who administered it. All that stuff got to be documented.

They do not play about controlled substances. So you make sure you documented everything. So we're talking about completing the patient care report. So the patient care report contains check boxes and a narrative portion.

The narrative portion of the patient care report should be detailed, written in a format accepted by your agency, accurate and complete and specific. Some services attack a copy of the readings to their documentations. Each of the following should be documented into narrative section. The consultations, the orders requested or received from medical control, refusal situations in which medical control was consulted.

Do not just write something like see refusal on back. Don't do that. Again, be detailed and specific about everything that happens during a call. There are many methods for narrative documentation.

EMS agencies and medical directors may prefer a specific method, so know whatever your agency likes to do, make sure you're writing in that method. Some writing styles for narratives like chronological order, which is basically telling the story in a story format from the time you were dispatched to the time the call's in. You have a SOAP method, which is basically a method that divides your patient care report into four different sections. You have the subjective information, the objective information, the assessment, and then the plan for treatment.

Regardless of the style of narrative report, use the same reporting method consistently. So don't switch how you do reports. Once you find a way that you like to write your reports, stick to that way.

Keep it nice and consistent. Don't switch. Don't be back and forth.

I use the SOAP method personally for where I work. Pertinent negatives should always be documented when writing an EMS report. So a pertinent negative is a record of a negative finding that warrants no care of intervention but indicate a thorough examination of history was performed.

So for example, if I'm running a call a pertinent negative would be the patient denies having chest pain. The patient denies having shortness of breath. The patient denies loss of consciousness.

So I've established that I've examined this patient. They said they did not lose consciousness or they were never unconscious at any point in time. is not hurting.

I heard from the patient's mouth, they said their chest is not hurting, so I'm not going down that route. And then the patient is not complaining of any shortness of breath. So when I hand you this patient, based on my report, I handed you this patient, they had no chest pain, they were breathing okay, and they was in a right state of mind.

All right, whatever happens after that, it's on you. But when I had them, it was documented. And again, sign sealed and delivered.

Spoken accounts may include statements of the patient's behavior, the MOI, the safety-related information such as the use of weapons, and the following may also be useful to list in the narrative section. So you always want to make sure disposition is valuable so the patient has like wallet, their watch, any kind of jewelry on them. You want to make sure that you document that and you make sure that patient leaves from your care to that next person's care with all their stuff and you document it in that patient care report.

Like, hey, yep, when I turned them over. I gave the patients first, the wallet and all that other stuff. Because again, for whatever reason, stuff likes to go missing in the hospital and you don't want it to come back on you. So you document all that stuff like, hey, when they was with me, when I transferred and handed them over, I handed them over with everything.

I didn't have none of their stuff. I make sure they had all their possessions. You and you will be you will be surprised how much stuff goes missing at the hospitals.

All right. So elements of a properly written report. Documentation accuracy depends on all the information being complete and precise.

The incident times, the narrative information, and all the check boxes are complete. Complete all sections of the PCR, even if a section was not applicable to a call. So leaving the boxes blank may raise questions in the completeness of the report. So if you have a section that if you have a section of your report that you didn't do, just put on not completed or not applicable. Put something in there, but don't leave it blank, because if you leave it blank, it's going to be assumed that you didn't do it at all.

Handwritten report should be legible, written in ink, neat and easy to read. Place all completed reports in a secure location that protects the patient's privacy agreed upon by you and your partner. A PCR needs to be completed in a timely manner, so make sure you get all your reports done as soon as possible. Some type of written record must always be left with the patient.

So a drop report or transfer report is a single page abbreviated form used as a memory aid during an EMS call. Leave a copy of that drop report or transfer report with the nurse or physician. All PCR should be free of the following.

any kind of special jargon, slang, or personal opinions. Leave that stuff out of your reports. Again, your report is factual, based upon the facts and facts of your objective information and the subjective information. Stick to the facts.

Again, that is a legal document. Don't be putting your opinions, don't be putting your emojis and your short form writing, your text writing. I know we're in a new generation that's coming up, so a lot of us didn't really pay that much attention. in English class, but you got the ways to properly write. You need to bring those to the EMS field.

Don't be, I'm telling you, you'd be surprised, man. I'm 36 years old and we get a lot of guys that are like in their twenties that come and start with the department. And you could tell like they're young because they'll do the report and you'll catch them. Like when you review their report, you'll catch them, like do some short form stuff.

Like they texted somebody. It's like, Hey man, this ain't going to fly. You got to write out, we write out your words in the adult world.

So just keep that in mind. Be certain that your documentation is not libelous. Remember libel. Libel is writing the false statements that could be harmful to a person's current or future reputation.

So be certain that your documentation is not libelous. All right. Only true and accurate statements should be documented. So be certain that your documentation is not libelous.

All right. Only true and accurate statements should be documented. Review your reports before submitting them to the receiving medical facility and your supervisor. So you review your reports for completeness, accuracy, grammar, spelling, and proper use of medical terminology and abbreviations.

All written reports reflect on the paramedic. Consequences of poor documentation. So inappropriate, inaccurate, and insufficient documentation can adversely affect the quality of care received by patients at the arrival at the hospital. Document what the patient or family member tells you and your findings from examining the patient will enhance the quality of care.

Remember to document the specific time a suspected stroke patient was last seen normal by family members, for example. Important to the window of time for treatment using fiber. So the reason why it's so important, like some, for example, like documenting when the last time a patient was seen normal that suffered from a stroke.

So when you have a stroke, again, that's something that we'll get into a little bit later. But right now, just going over briefly, when you have a stroke, what happens is you get a clot up in your brain. And what they do for the clot is they give you something called fibroanalytics, basically like a clot buster.

So there's a certain amount of time, like a window, that you are able to receive that treatment. So they were last seen normal over 24 hours ago. they can no longer receive the clock buster because it can have a negative impact on whatever their stroke symptoms. OK, so that's an example of why it is important to ask questions like that and make sure you document everything and all the information that the family is giving you. Poor documentation skills can affect the paramedic reputation.

There are significant legal implications of documentation. Poorly written, inaccurate, or ineligible reports might lead a judge or jury to decide in favor of the plaintiff. A lawyer may decide not to pursue a case when the documentation reveals a correctly written and well-documented report. report.

So if your reports is good and these people out here just trying to get some money, they're just trying to sue you off the strength of just trying to, you know, see if they can get over. If your report is spot on and they can't poke no holes in it, a lot of times don't even want to mess with you. So again, like I told you guys, I've been... been deposed before. I've been reached out to like, hey, we want to do a deposition based upon this case.

And they don't look at the report I wrote and they just tell me, you know, we don't need you. Like, never mind. And again, that's just because I make sure everything, you can't poke no holes in it. You can't poke no holes in it.

Case closed, case dismissed, man. So that's why documentation is very, very important. Errors and falsifications. So at times it is necessary to revive or correct a patient care report.

If a revision or correction must be made to report, note the date and time of that revised report. Include the purpose for writing the revision or making the correction. and never discard or destroy the original patient care report.

So if you got to make any corrections, you go through those steps, but don't throw away that own report. Because again, you're going to give off the impression you're trying to destroy evidence and you're trying to hide something. If you got to make a correctional... a revision, you just put it and attach it on top of the previous report that you did.

And only the person who wrote the original report can make any revisions. So you can't have a friend say, hey man, I'm about to get off shift. Can you correct this for me?

That ain't gonna fly. If you need to make a revision to your report, you're the only person that can do it. Routine administrative report handling and reviews are necessary for entering information in the computer databases, billing for services, and quality assurance monitoring. Administrative activities should never involve altering or rewriting a report or portions of it.

So if they don't like what they see in the report, your administrator or your supervisor, they'll kick it back down to you and be like, hey, you need to fix this. That type of deal. Do not erase information, scribble through errors, use correction fluid or correction tape.

Remember the PCR is a legal document. Most electronic reporting systems will allow for amendments but will prevent erasure in a completed document. Refer to the system's direction as to how to make an amendment to the original document.

If there is no way to electronically change the report, follow the same procedures for a written document after printing the report. Addendums may be needed to add forgotten important information to a report and write statements of events for matters related to quality assurance or risk management and answer any complaints. Addendums should include a note that the addendum was added to the original report, reason for the late entry, date of entry and time of entry, and also signature of the author. Loss reports pose huge legal implications, so all paramedics are responsible for ensuring their reports are completed and turned in as required by policy or procedure. Do not keep copies of these reports.

Trying to recreate PCRs is irresponsible and possibly illegal. Ain't no possibly, it's illegal. Record keeping may be a legal requirement in your state.

and there may be a specific time requirement for submission of these reports. When you're documenting incident times, accurate timekeeping is essential to all EMS operations. So the role of timekeeping falls to dispatchers.

So dispatchers are your timekeepers. They they keep everything in a time. Every time stamp the dispatch keeps. They put it in your CAD system so you can update it to your report. So you don't have to worry about that on seeing your dispatchers usually keeping your times, whether that's the time you dispatch, the time you arrive, the time you start transporting to the hospital, the time you arrive to the hospital.

Dispatch keeps keeps track of all of that for you. So that's one less thing you have to worry about. Just make sure you include it in your report. You always include that into your report. and you compare times with dispatchers to ensure accuracy and proper timekeeping that yours and yours dispatchers clocks are synchronized discrepancies can lead to controversies controversies in the courtrooms so again always make sure you and your dispatch is on the same page when it comes to those times so following incident times are crucial to track okay you want to make sure you track the time of the call time of dispatch time of arrival at the scene time with the patient Time of any medication administration you do.

Time of any medical interventions that you do. Time of departure from the scene. Time of arrival at the medical facility.

Time you transferred to care. And your time back in service. Times are kept in military units to avoid confusion. So we operate on 2400 clock in EMS. 2400 hour clock in EMS.

All right, guys. That's chapter six. It's documentation.

Transcript for:Essential Guide to EMS Documentation

Transcript for:
Essential Guide to EMS Documentation