Documentation: Basically Very Important

proper recording can make or break you

 

 
 
 

Dennis Edgerly, EMT-P | | Tuesday, April 22, 2008


The call is over. You're cleaning and restocking your ambulance. You provided the best care possible and gave a thorough report to the emergency department (ED) physician. Unfortunately, the patient died. Now it's time to write the report, documenting all of the events surrounding your assessment and care of the patient.

EMS reports don't just get filed, never to be looked at again. These reports become part of the patient's file at the hospital. In addition, the EMS agency should keep a copy as a record of medical care. A third copy can be used for billing. Medical records are usually maintained a minimum of five years, which is time required by Medicare. Some states require records be maintained up to 25 years. EMS reports may be read by the ED physician, surgeons, the patient's primary care physician and rehabilitation staff. Reports may be used for legal purposes in cases such as domestic violence or child abuse. EMS reimbursement may be affected by the clarity of the EMS report. Statistical data and research information can be extracted from these reports. Finally, if someone calls into question the medical treatment provided by the EMT, the report they wrote will be their savior -- or their demise.

The report written by the EMS provider is the only document surviving the call that will describe prehospital assessment and treatment. This means if questions arise about the patient presentation on scene, treatment provided en route to the hospital or patient statements, the document everyone turns to for answers is the EMS report. Different templates are available to guide the EMT author, but what information should be included?

Required information includes date and location of the call, identifying patient data, times and transport destinations. This column will focus on the patient care narrative.

The perfect report is well organized, free of misspellings and leaves no room for interpretation by the reader. An EMS patient care report should include what was seen, heard and done. It shouldn't include subjective information or information about other patients. Abbreviations should be approved by the agency and used with caution.

Perhaps the most difficult part of writing a patient care report involves the narrative. When documenting the scene, describe what you see. What's the mechanism of injury? Where was the patient located? Were they sitting in a chair in the kitchen or lying on the floor in the garage? Did you see power tools, ladders, beer cans or drug paraphernalia nearby? Was the patient in the front seat of a car or walking around? If a vehicle was involved, describe the damage to the vehicle. Give the reader a clear picture of the milieu as it pertains to the patient's injury or illness.

The chief complaint is the reason the patient is being treated. Describe this as clearly as possible. Mechanisms are not chief complaints. For example, a chief complaint is ankle pain, not falling off a ladder. Using the patient's words is appropriate. Be sure to include associated symptoms surrounding the chief complaint, such as dizziness with nausea and vomiting or shortness of breath with chest pain.

Two histories require documentation. The first is the history of the present illness, which can be guided by the mnemonic OPQRST (read more about QPQRST in January's article, "Assessing Your Assessment"). The second is the past medical history. Document all allergies to drugs, food and the environment. Also note prescribed medications and patient compliance (or non-compliance), as well as over-the-counter (OTC) medications since they can interact with prescription medications. Past medical history as it pertains to the current injury or illness is important. Occasionally childhood diseases may be significant to adult illnesses, such as in the case of chicken pox and shingles. Remember to include family history. Document their last oral intake to include what and when they ate. With female patients, document information about their last menstruation, including any abnormality and when it occurred. This history is commonly guided by the mnemonic SAMPLE.

You should organize your assessment by body region or organ system. In other words, document assessment of the head, neck, then chest, etc. or document assessment of the integumentary system, cardiovascular system etc. Avoid such phrases as "assessment negative" because they don't describe the type of assessment done or whether an assessment was done. In addition, documenting positive findings is just as important as negative findings. Document what you see. Avoid such subjective terms as "some" or "small". Use a 0 10 scale to document pain. Approximate size of wounds or describe body area injured. Document your re-assessment after treatment and any patient change.

The record of your treatment needs to be detailed as well. Don't just write "airway controlled". Instead document how it was controlled. For example, "Head tilt chin lift, OPA placed, patient bagged with bag mask". Write down the patient's response to your treatment, including desired and side effects, or if the patient didn't respond.

Documentation of transport should let the reader know you returned to the hospital emergent or non-emergent, and it should be clear why that decision was made. In larger cities with multiple hospital choices, destinations must be documented to verify patients were transported to the closest, most appropriate facility, such as a trauma or stroke center.

The trauma surgeon reviewed your report and was able to get a clear idea of the mechanism involved in your patient's injuries. Your medical director read your report and was able to justify your decision to pass the closest hospital, which is not a trauma center, and transport to a Level I trauma center. Three years after the call, you were subpoenaed to testify in the trial of the person who caused your patient's accident. You were able to refer to your report for all the details of the call.

Above, I made reference to the perfect report and the components of that report. Unfortunately, the perfect report probably doesn't exist. However we, as EMS professionals, can strive to write the best report possible.




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Related Topics: Administration and Leadership, Operations and Protcols

 
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Dennis Edgerly, EMT-Pbegan his EMS career in 1987 as a volunteer firefighter EMT. Currently he's the paramedic education coordinator for the paramedic education program at HealthONE EMS. Contact him at Dennis.Edgerly@Healthonecares.com.

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