documentation

Emphasis on documentation has increased dramatically, paralleled by sophistication of patient care and rise in medical litigation. Emphasis on documentation can also be attributed to increased quality assessment/improvement, educational levels, and awareness of EMS professionals.

Documentation should be practiced just like any other technical skill. Refining a few definitions and procedures will help avoid pitfalls, enhance the delivery of patient care, and reduce the risk of litigation. Documentation procedures -

  • Provide a record of scene information that may not be available from any other source.
  • Provide continuity of care from one healthcare professional to another.
  • Provide medicolegal evidence.
  • Reveal any significant changes in the patient’s condition.
  • Provide an internal tool for statistics, budgeting, and quality assessment/improvement.
  • Reveal problems with record-keeping procedures.

Procedure

  1. Collect all patient demographic information (e.g., name, age, sex, address).
  2. Complete all blanks and check all pertinent boxes on the call report form.
  3. Begin the narrative by documenting the patient’s level of consciousness (LOC), age, and how he or she appears initially. “20 y.o. male found supine on living room floor, conscious and alert.”
  4. Document patient’s chief complaint. This should be in the patient’s own words and included in quotation marks, if possible.
  5. Document history of present illness. This should be given in chronological sequence and should include the time of onset, frequency, location, quantity, character of the problem, setting, and anything that aggravates or alleviates the problem.
  6. Document review systems and physical assessment findings, including any pertinent positives or negatives. This should be a head-to-toe assessment, when indicated.
  7. Document any significant past medical history, including surgeries, hospitalizations, illnesses, or injuries.
  8. Document allergies and current medications.
  9. Document treatment procedures, who performed the procedures, and the patient’s response or lack of response to treatment. Include times.
  10. Document vital signs and orders, with times.
  11. Attach all EKG strips documented with date, time, lead, and patient’s name.
  12. Complete Glasgow Coma Scale, with times.
  13. Obtain receiving nurse’s and doctor’s signature as needed.
  14. Leave copy of report with patient’s chart.

Definitions

Anatomic figure, injury identification is an anterior and posterior figure located on the call report form. It should be used to mark and label the patient’s injuries.

Chief complaint (CC) is a brief sentence or statement describing the patient’s reason for seeking medical attention. It should be the patient’s own words if possible (e.g., “My chest hurts” or “I can’t catch my breath”).

Demographic data include name, age, date of birth, address, occupation, and nearest relative.

History of present illness/injury (HPI) documents events or complaints associated with the patient’s deviation from normal health. This should correlate with the reason the person is seeking medical attention only for his or her current medical problem, not past problems (e.g., “While painting last night around 10:00 PM, I began having this dull pain in my chest” or “I lost control of my motorcycle and slid about 50 feet down the roadway”).

Past medical history (PMH) documents any significant past medical or traumatic illnesses that relate to the patient’s present illness or injury. These data should include hospitalizations, surgeries, illnesses, or injuries.

Pertinent negative is the absence of a sign or symptom that helps to substantiate or identify a patient’s condition. For example, a patient with a suspected dislocated hip usually has decreased range of motion; if the patient has good range of motion, this should be documented.

Pertinent positive is the presence of a sign or symptom that helps to substantiate or identify a patient’s condition. For example, if a patient falls and complains of leg pain, an obvious bend of the midshaft lower leg is a positive sign of injury and should be documented.

Physician orders are physician-directed advanced life support (ALS) or basic life support (BLS) treatment orders.

Response to treatment is the patient’s response or lack of response to the care that was rendered.

Review of systems (ROS)/physical assessment are two separate categories that should be combined in the EMS field assessment. The review of systems is a head-to-toe review of all complaints system-by-system. The physical assessment is a head-to-toe, hands-on examination. These two should be combined for EMS documentation into the complaints and physical findings.

Treatment is the care rendered to the patient.

Additional documentation tips

  1. Do not blacken through any documentation; draw one line through it and place your initials beside it.
  2. Use correct spelling.
  3. If normal protocol or standard of care was not followed, document why.
  4. Document any delays or problems responding, gaining access, or transporting the patient. Include an explanation of the problem and the length of the delay.
  5. Document any domestic problems that might have arisen.
  6. Use a supplement sheet when necessary. The narrative does not have to be squeezed into a small area on the call report form.
  7. Use approved medical abbreviations.
  8. Write legibly, clearly, and concisely.
  9. A patient who presents with trauma and has experienced a significant mechanism of injury should have a documented head-to-toe physical assessment, not just of areas of major complaint.
  10. Complete the form as soon as possible; it enhances accuracy.
  11. REMEMBER, IF IT WAS NOT DOCUMENTED, IT WAS NOT DONE!

Documentation by Call Type

The following lists are specific pieces of information that may be necessary for complete and accurate documentation. This information is not in prioritized order. These lists indicate suggested items that should be included in your documentation.

Car Crash

  • Patient location in auto
  • Seatbelt or shoulder harness usage
  • Loss of consciousness
  • Velocity of accident
  • Type of accident (head-on, roll-over)
  • Type of vehicle damage
  • Patient trapped or pinned
  • Delay in extrication
  • Patient ejected from vehicle
  • Patient ambulatory at scene

Coma

  • Sign or history of trauma
  • History of diabetes or seizure
  • Drug or alcohol ingestion
  • Last seen conscious by whom and when
  • Position found
  • Scene survey
  • Pupils
  • Response to painful or verbal stimulus
  • GCS

Diabetes

  • Level of consciousness
  • Insulin-dependent or oral hypoglycemics
  • Last meal
  • Amount of exercise
  • Last insulin injection and how much
  • Any recent illnesses
  • Gradual or rapid onset of symptoms
  • Kussmaul breathing
  • Alcohol or other drug use

Trauma

  • Level of consciousness
  • Type of accident
  • Ambulatory after accident
  • Head-to-toe assessment
  • Special circumstances
  • Scene survey

Overdose

  • Level of consciousness
  • Whether overdose was witnessed or not
  • Medication or substance ingested
  • Amount ingested
  • Time of overdose or best approximation
  • Any associated alcohol or drug consumption
  • Prior overdose or suicide attempts
  • Patient admission of intent to harm self
  • Police notification

Chest Pain

  • Activity at time of pain onset
  • Radiation
  • Pain on movement
  • Onset (gradual or sudden)
  • Breath sounds (presence, quality, and quantity)
  • Dyspnea
  • Nausea and/or vomiting
  • Diaphoresis
  • Jugular venous distention
  • Peripheral edema
  • Pain character (sharp, dull)

For any pain, PQRST format can be used

  • Pain on scale 1-10

Gunshot wound

  • Number of wounds
  • Location of wounds
  • Type of weapon (handgun, rifle, or shotgun)
  • Patient’s position at time of shooting
  • Perpetrator’s position at time of shooting
  • How many shots heard
  • Head-to-toe assessment
  • Note caliber of weapon, if it can be confirmed
  • Amount of external hemorrhage noted
  • Police notification

No transport call

  • Clear documentation
  • Patient demographic information
  • Patient informed of consequences of not being transported
  • Methods used to encourage patient to accept treatment/transportation
  • Alcohol or other drug usage
  • Level of consciousness
  • Patient’s reason for contacting EMS
  • Individual responsible for contacting EMS, if not the patient
  • Vital signs
  • Physical exam
  • Cancellation en route noted (e.g., police, fire, dispatch)
  • Patient’s cooperation with your attempt to deliver care and transport
  • Signature of patient
  • Signature of witnesses

Pediatric

  • Level of consciousness (crying, uninterested)
  • Parent recognition
  • Consolable
  • Fontanelles (full, flat, or sunken)
  • Child’s weight
  • Skin condition
  • Finger grasp
  • Response to pain
  • Fever
  • Length of illness
  • Medications or treatments administered

Respiratory distress

  • Level of consciousness
  • Skin color and temperature
  • Amount of distress (mild, moderate, or severe)
  • Audible respiratory sounds (wheezes, rales, rhonchi)
  • Onset of distress (gradual or sudden)
  • Activity at time of onset
  • Cardiac history
  • COPD history

Breath sounds (present, absent, wheezes, rales)

Seizure

  • Level of consciousness
  • History of seizures
  • History of alcohol or other drug usage
  • History of diabetes
  • Sign or history of injury
  • Number of seizures
  • Duration of seizures
  • Motor activity observed during seizure (e.g., where began and spread)
  • Medication history (i.e., takes seizure or diabetic medications regularly)
  • Pupils
  • Breath sounds
  • Head-to-toe assessment
  • Cardiac history

Pregnancy

  • Last menstrual period
  • Estimated due date (if known)
  • Number of pregnancies (gravida)
  • Number of pregnancies carried to term (para)
  • Prenatal care history (none, some, continuous)
  • Complications with this pregnancy
  • Complications with other pregnancies
  • Water broke
  • Back pain
  • Urge to push
  • Vaginal discharge
  • Multiple births
  • Type of pain
  • Duration of pain
  • Regularity of pain
  • Interval between pains
  • Progress during transport

Stab wounds

  • Number of wounds
  • Location of wounds
  • Amount of external hemorrhage noted
  • Patient’s position at time of stabbing
  • Perpetrator’s position and knife angle at time of stabbing
  • Head-to-toe assessment
  • Scene surveyPolice notification

Documentation Checklist

Procedure Possible Points

points awarded

Obtain demographic information / 1
Clearly define chief complaint / 1
Note initial level of consciousness / 1
Define location/presentation / 1
Obtain history of present illness / 1
Perform complete physical assessment / 1
Note pertinent positives / 1
Note pertinent negatives / 1
Note pertinent past medical history / 1
Document allergies / 1
List current medications / 1
Record treatment / 1
Record response to treatment / 1
Place EKG strip. (ALS services only) / 1
Document orders / 1
Document times / 1
Record vital signs / 1
Complete Glasgow Coma Scale / 1
Completed Trauma Score (if indicated) / 1
Obtain appropriate signatures at receiving facility / 1
Total Points / 20

COMMENTS:______

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PAPERWRK.DOC