Captain Obvious writes a column for JEMS

[JPINFV]

I'm tempted to put this is gen. discussion, but the topic fits here better.

Documentation: Basically Very Important

* Dennis Edgerly, EMT-P

* 2008 Apr 26

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) 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.

http://www.jems.com/news_and_articles/colu..._Important.html

So, um, I'm kinda of scratching my head on this one. It seems that he's saying if you assess it then you should document it and that you shouldn't be adding any outside or subjective language to a report. Maybe I'm being a little hard headed here, but shouldn't this be the sort of thing that would be taught in class? If not there, then at least by the company that you work for? I feel that there's something drastically wrong if a provider's best source of knowledge for writing a PCR is JEMS.

[DwayneEMTP]

Sure. But what harm comes from revisiting it again, and again? And if you didn't get this in class (Hard to imagine) is the world a better place if you never get it at all?

I don't really see an issue with article. It seems pretty clear, to the point, and reminds chuckleheads (like me) that someday you may have to defend every word in your PCRs, and perhaps even more so the words that never made it in.

One of the things that impressed my about doing clinicals in CO Springs is that the medics were always comparing notes. I was taught by each preceptor that I should believe that I'll never write a perfect PCR, though my goal should always be to write a perfect PCR. So in the EMS lounge it was a daily occurrence for medics to ask each other questions about a better way to phrase something, how to spell something, etc. And these guys..well, when I read their PCRs it made mine, which I was pretty proud of at one point, sound like fourth grade nonsense.

My point is simply that writing a PCR, at least a really good PCR, can, and seems to, require an evolution. A sharp bell curve in the beginning that resolves into a miles long plateau that never again reaches baseline.

Though I can see your frustration at the well noted lack of education, I don't see where a regular review is a bad thing...

Dwayne

[Dustdevil]

Most medic schools I have seen teach very little more about documentation than the old, "If it isn't charted, it never happened." And a great many employers these days have PCRs that are nothing more than a page of boxes to check and drop-downs to select. Consequently, people may go through a twenty-year career without ever writing a real chart. When they decide to go moonlight at a real EMS service, they get a rude wake-up.

I learned a lot more about charting in the police academy than I did in paramedic school. One reason that cops usually make much better medics than firemonkeys do.

[JakeEMTP]

We use the ePCR here. I agree with Dust that it is a series of check boxes and drop downs. However, occasionally, you are presented with a patient who doesn't fit in to " the box". That is when the particular check box called "other" comes in, in my opinion. After checking "other", there is another box, for you to check and you can explain, in your own words what you are presented with. I use it frequently even if my patient's condition satisfies the other areas, I like to explain what I see. Some of the more experienced medics in my area say I over document. I didn't think that was possible.

As always, there is ample room to write a narrative, and there is no maximum words as I've heard of with some electronic programmes. I suppose though, since this is the only programme I have been exposed to thus far in my short career, I am perhaps biased.

I believe Dwayne to be correct when he states that reviewing documentation over and over isn't necessarily a bad thing. Eventually some of it will sink in, even if they are chuckleheads. :wink:

[firespec35]

Thats actually a good article. I think I will get my boss to print it out to give to the newbies.

When I was in medic school last year I had to write exactly 2 actual reports. Most of my clinical forms I wrote the closest to report style I could but no real emphasis was paid to how to write a run report, even remedial.

Since I do Special Event EMS only, My reports get called into court a lot (About once every 2 years) It has always been cause the venue has been sued. I usually use up all of the narrative area plus some on mine. Some of my "partners" I've been stuck with write a line or two and call it good. These are experienced providers who all work with some sort of other ambulance company and most do 911. I feel weird every time trying to work with these guys but I have to do it anyways. I'd hate to have to go into court with one of their reports 3+ years later.

[dahlio]

When they decide to go moonlight at a real EMS service, they get a rude wake-up.

Tell me about it, going from writing a volly pcr, to a professional service pcr, it's a huge difference. I've finally gotten the hang of it, but your pcr is much more complete then a volly pcr. The narrative is the biggest part of the pcr, and that's where your focus should be on a chart.

One of my partners the other day, asked me why I wrote about my oxygen administration, along with the tick marks. I told him that tick marks don't explain why I chose to give oxygen, nor does it explain whether it had an effect on the patient. Tick Marks are guidelines, but nothing can replace a narrative.

[Kaisu]

Most medic schools I have seen teach very little more about documentation than the old, "If it isn't charted, it never happened."

We have to turn in 20 charts this semester. The marking is very tough. As an experiment, I turned in a chart that was written by my preceptors. (The first chart was allowed a take back - in other words you could turn it in but it didnt have to count if you didnt want it to.) My preceptor's chart earned a 23/30. The charts I have turned in subsequently have earned 29 and I actually got a 30 on one of them.

I love the standards that my school has set.

[Arkymedic]

We have to turn in 20 charts this semester. The marking is very tough. As an experiment, I turned in a chart that was written by my preceptors. (The first chart was allowed a take back - in other words you could turn it in but it didnt have to count if you didnt want it to.) My preceptor's chart earned a 23/30. The charts I have turned in subsequently have earned 29 and I actually got a 30 on one of them.

I love the standards that my school has set.

Not trying to bust on you because you do seem to be smart and actually try to learn; however, is your instructor aware of your "experiment"? If not you just admitted to plagerism and unethical behavior. Just a kind of friendly reminder to be careful of your actions and words.

[Kaisu]

I didn't make myself clear.. the first chart was a gimme ... it was ours to test the marking process so that we would see what was required.. sorta a test balloon.. we had the option of taking the mark but that I won't do... I will be submitting 20 of my own.

I wanted to see how what was required in school translated to the real world. I don't see that I thwarted the educational process in anyway - on the contrary, I learned more than what the exercise was designed to teach.. a good thing don't you think?

[Arkymedic]

I didn't make myself clear.. the first chart was a gimme ... it was ours to test the marking process so that we would see what was required.. sorta a test balloon.. we had the option of taking the mark but that I won't do... I will be submitting 20 of my own.

I wanted to see how what was required in school translated to the real world. I don't see that I thwarted the educational process in anyway - on the contrary, I learned more than what the exercise was designed to teach.. a good thing don't you think?

I think it was great that you learned from the exercise and glad you did not take the grade. We have had a few removed from programs due to academic dishonesty from turing in preceptors reports. This was fixed when we were required to write a run report on every pt during our truck internship and the preceptor had to sign off on the accuracy of every report we wrote.