Chapter 37: The Critical Care Paramedic in the Hospital

Transcription

METS EPCR AND CHARRT
METHOD OF REPORT
WRITTING
Limmer/Le Baudour, EMT Complete: A Basic Worktext
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
Documenting your EPCR
with 2016 guidelines
Reasons for Accurate
Documentation
Continuity of care
Education
Administration
Quality
Research
Legal requirements
Forms in Court
Documentation may be called to court
– As evidence in legal action
• e.g, patient sues those who caused injury
– As evidence in criminal action
• e.g., your patient was victim of crime
• Your patient is accused of a crime
– When you or another member are accused
of improper care
Good documentation for court
You may be called to testify about
– Your observations
– What others did or said
– What care you provided
– Whether or not report accurately depicts
events of the call
Minimize Liability
“If you didn’t document it, you didn’t
do it.”
Proper documentation reduces
exposure of you and your agency
The pt has the right to see their chart,
so watch what you right
Falsification
One of the 5 deadly sins highlighted in
our COGs resulting in termination
Honesty and integrity are essential traits
for EMS
Do not write false information
Do not leave out information from
reports
Run Data




Call #
Run type
Company
Call Date
– Save
 Dispatch Number
 Reason for Dispatch
 Response Mode
– Has been deleted
Run Data
 Dispatch Urgency
 Transport Urgency
– If IV, not routine
 Pick up
– Jasper, Joplin…
 Drop off
– Use correct drop off
Patient Data
 Pt name
– By search or new input
– Make sure it is correct
name
 Social Security
 Date of birth
– Age
 Phone number
 Address
Patient Data
 At pt time
 Vital signs
–
–
–
–
–
–
–
–
–
–
Time
Crew
AVPU
Pulse
Respirations
BP
Glucose
EKG Rhythm
Pulse OX
Pain Scale Pre and Post
Vitals
FLOW CHART
Narrative Documentation
Chronological order
CHARRT
The point of the narrative is to paint the
picture. It is written documentation of
what you heard, saw, assessed and
performed.
Guidelines for Narrative
Documentation (1 of 2)
 Avoid documenting
conclusions that are
not fact-based
 Use “Patient states”
to document
information you
receive from patient
Guidelines for Narrative
Documentation (2 of 2)
Include relevant observations such as
– Mechanism of injury
– Suicide notes
– Blood loss
– Patient’s living conditions
– Care given by bystanders
Narrative Comments
 Required statements
– How responded
•
Emergency/non-emergency
– To where
•
Residence…or be specific
– For what reason
•
Dispatch reason
 C.H.A.R.R.T.
CHART
Chief complaint
History
Assessment
Rx (or treatment)
Response to treatment
Transport
CHART

C/C: WHAT IS CHIEF COMPLAINT PER PT?

HPI: INFO GIVEN BY OTHERS OR PT. ANY CARE ALREADY PROVIDED BY
SOMEONE ELSE. BRIEF HX OF WHAT BROUGHT EMS TODAY.

AX(HEENT): CAOX4 OR LOC, PERL OR DIFFERENT, AIRWAY PATENCY,
SYNCOPE OR NO IF RELEVANT. WOUNDS FOUND, BLEEDING ETC.
– NECK: JVD? TRACHEAL DEVIATION? PAIN?
– CHEST: LS CTA BILAT OR ADVENTITIOUS SOUNDS NOTED, IS PT
DYSPNEIC OR NOT, IS THERE PAIN (INCLUDE SCALE 1/10) , IN
TRAUMA NOTE INJURIES HERE.
CHART
– ABD: SOFT OR HARD, PAIN OR NOT, ANY N/V, INJURY NOTED,
PULSATILE MASS IF RELEVENT. WHAT QUADRAIN IS THE PAIN
LOCATED
– PELVIS: STABLE OR NOT IN TRAUMA, ANY PAIN, ANY
INCONTINENCE OR NOT.
– EXT: DISTAL NEURO STATUS, PAIN OR NOT, INJURY OR NOT,
EDEMA OR NOT.
– BACK: PAIN OR NOT, INJURY, DEFORMITY NOTED OR NOT.

RX: ANY CARE YOU HAVE PROVIDED FOR THE PT. FOR EXAMPLE: SPO2,
O2, SPO2 AFTER O2, EKG, IV TYPE AND SIZE/SITE. GLUCOSE READING.
MEDS GIVEN, ETC.

RESPONSE: WHAT WAS YOUR PATIENTS RESPONSE TO YOPUR
TREATMENT

TX: ANY CHANGE OR NOT ENROUTE TO RECEIVING FACILITY.
DOCUMENT IV PATENCY IF APPLICABLE ON ARRIVAL. CARE RELEASED
TO? EOR (END OF REPORT)
SELECT NARRATIVE
NARRATIVE
Transfer Narrative
 Required statements
– Why pt is being transported
• Why do they need an ambulance
– Complaint at hospital admittance is not to be used in chief
complaint area on transfer out
– 96 hr hold is not a chief complaint
– If PT is bed ridden is marked on PCS, write why pt is bed
ridden
• If they are not bed ridden, then write why they are not
– Why is pt going out of town
• Why not Freeman or Mercy , Why is this patients condition not
being handle locally,
• Example: FW unable to perform procedure due to patient nero
status, Pt being sent to higher level of care for neurological
surgery and further specialized treatment.
Transfer Narrative
 Do not write “pt does not need ambulance”
– Not opinion
 Must have medical history
 Make sure you have PCS on all Transfers and NonEmergency transports
– Make sure documents is filled out completely
– RN or Doctor’s Name needs to be legible
• Signed and printed with title
HIPAA
 Must get signature from every pt
 Other signature if:
– Pt minor
– POA
– Refusal of care
 Not able to sign
– YOU MUST HAVE THIS FILLED OUT IF THE
PATIENT IS UNABLE TO SIGN.
– You also need to fill out the comment portion
explaining why they cant sign
Patient Refusal
 Document
– Assessment and care
performed
– Patient of legal age and
has ability to make
informed decision
• e.g., not intoxicated or
otherwise incompetent
– Patient knew risks
– Make every effort to
convince patient
– Efforts to protect patient
• e.g., contacting family
member(s)
Guidelines for Patient Refusal
Patient must be C A O X4
EMS provider must advise the patient of
the risks of refusing treatment up and
including death
This must be documented
When in doubt call med control
Conclusion
Documentation is a crucial
Provides lasting memory of quality care
Poor documentation puts you and
METS at risk for criminal charges, law
suits, etc.
You should always write your narrative
so in two years you can recall that
patient and the event.

Chapter 37: The Critical Care Paramedic in the Hospital

Transcription

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