Emergency Medical Responder First on Scene TENTH EDITION

Objectives 1. Define the following terms: a. b. c. d. Continuity of care Electronic

Objectives 4. Describe the minimum data set required for the documentation of patient care.

Objectives 7. Demonstrate the ability to accurately document a simulated patient encounter. 8. Properly

Topics Patient Care Reports Methods of Documentation Emergency Medical Responder: First on Scene, 10/e

PATIENT CARE REPORTS Emergency Medical Responder: First on Scene, 10/e Christopher J. Le Baudour

Patient Care Reports • Documentation is a permanent record of provided care. • Reports

Figure 8. 1 Example of a typical paper-style patient care report (PCR) form. Emergency

Figure 8. 2 Electronic documentation of an emergency call is becoming more common. Emergency

Patient Care Reports • Reasons for accurate and complete documentation § § § Continuity

Patient Care Reports • Elements of the PCR § Run data • Information about

Patient Care Reports • Information in narrative should be objective rather than subjective. §

Patient Care Reports • Minimum Data Set Time incident was reported to 911 Time

Patient Care Reports • Minimum Data Set § Time patient care was transferred to

Patient Care Reports • Correcting Errors § Cross out incorrect item with single line,

Figure 8. 3 An example of how to properly document an error in documentation.

Think About It • The quality of your documentation is reflective of the care

METHODS OF DOCUMENTATION Emergency Medical Responder: First on Scene, 10/e Christopher J. Le Baudour

Methods of Documentation • Paper forms § PCR forms filled out by hand •

Methods of Documentation • PDAs or handheld computers § Specialized software allows emergency care

Methods of Documentation • Laptop computers § Software allows responders to complete PCR on

Figure 8. 4 A typical electronic tablet used for documenting patient care. Emergency Medical

Methods of Documentation • Data-enabled cellular devices § Advanced cellular data devices operate PCR

Think About It • How might electronic PCR be useful during an emergency with

SUMMARY Emergency Medical Responder: First on Scene, 10/e Christopher J. Le Baudour | J.

Summary • Patient care documentation is important. § Continuity of medical care to legal

Summary • PCR main categories § Run data § Patient data • Completed using

Summary • Each PCR has a minimum data set as defined by U. S.

Summary • Patient care documentation completed § Traditional paper-based forms § High-tech handheld computers

REVIEW QUESTIONS Emergency Medical Responder: First on Scene, 10/e Christopher J. Le Baudour |

Review Questions 1. What is the purpose of the PCR? 2. What elements are

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Emergency Medical Responder First on Scene TENTH EDITION CHAPTER 8 Principles of Effective Documentation Emergency Medical Responder: First on Scene, 10/e Christopher J. Le Baudour | J. David Bergeron Copyright © 2016, 2011, 2009 by Pearson Education, Inc. All Rights Reserved

Objectives 1. Define the following terms: a. b. c. d. Continuity of care Electronic documentation Minimum data set Patient Care Report (PCR) 2. Explain the purpose of the patient care report. 3. Describe the elements of a typical patient care report. continued on next slide Emergency Medical Responder: First on Scene, 10/e Christopher J. Le Baudour | J. David Bergeron Copyright © 2016, 2011, 2009 by Pearson Education, Inc. All Rights Reserved

Objectives 4. Describe the minimum data set required for the documentation of patient care. 5. Explain the procedure for correcting errors made during documentation. 6. List various tools used to document patient care in the field setting. continued on next slide Emergency Medical Responder: First on Scene, 10/e Christopher J. Le Baudour | J. David Bergeron Copyright © 2016, 2011, 2009 by Pearson Education, Inc. All Rights Reserved

Objectives 7. Demonstrate the ability to accurately document a simulated patient encounter. 8. Properly correct an error made during documentation. 9. Value the importance of complete and accurate documentation. Emergency Medical Responder: First on Scene, 10/e Christopher J. Le Baudour | J. David Bergeron Copyright © 2016, 2011, 2009 by Pearson Education, Inc. All Rights Reserved

Topics Patient Care Reports Methods of Documentation Emergency Medical Responder: First on Scene, 10/e Christopher J. Le Baudour | J. David Bergeron Copyright © 2016, 2011, 2009 by Pearson Education, Inc. All Rights Reserved

Patient Care Reports • Documentation is a permanent record of provided care. • Reports may be handwritten or electronic and recognized by different titles. § Run reports § Patient care reports § Prehospital care reports Emergency Medical Responder: First on Scene, 10/e Christopher J. Le Baudour | J. David Bergeron Copyright © 2016, 2011, 2009 by Pearson Education, Inc. All Rights Reserved

Figure 8. 1 Example of a typical paper-style patient care report (PCR) form. Emergency Medical Responder: First on Scene, 10/e Christopher J. Le Baudour | J. David Bergeron Copyright © 2016, 2011, 2009 by Pearson Education, Inc. All Rights Reserved

Figure 8. 2 Electronic documentation of an emergency call is becoming more common. Emergency Medical Responder: First on Scene, 10/e Christopher J. Le Baudour | J. David Bergeron Copyright © 2016, 2011, 2009 by Pearson Education, Inc. All Rights Reserved

Patient Care Reports • Reasons for accurate and complete documentation § § § Continuity of care Education Administration Quality assurance Legal Emergency Medical Responder: First on Scene, 10/e Christopher J. Le Baudour | J. David Bergeron Copyright © 2016, 2011, 2009 by Pearson Education, Inc. All Rights Reserved

Patient Care Reports • Elements of the PCR § Run data • Information about call § Patient data • Patient information • Sections of the Report § Fill-in § Check boxes § Narrative Emergency Medical Responder: First on Scene, 10/e Christopher J. Le Baudour | J. David Bergeron Copyright © 2016, 2011, 2009 by Pearson Education, Inc. All Rights Reserved

Patient Care Reports • Information in narrative should be objective rather than subjective. § Objective • Straightforward facts § Subjective • Up for interpretation • May include descriptions Emergency Medical Responder: First on Scene, 10/e Christopher J. Le Baudour | J. David Bergeron Copyright © 2016, 2011, 2009 by Pearson Education, Inc. All Rights Reserved

Patient Care Reports • Minimum Data Set Time incident was reported to 911 Time of dispatch Time of arrival at patient's location Time patient was transported from incident location § Time patient arrived at destination (e. g. , hospital, aid station) § § continued on next slide Emergency Medical Responder: First on Scene, 10/e Christopher J. Le Baudour | J. David Bergeron Copyright © 2016, 2011, 2009 by Pearson Education, Inc. All Rights Reserved

Patient Care Reports • Minimum Data Set § Time patient care was transferred to more advanced providers § Patient's chief complaint § Patient's vital signs § Patient's demographics • Age, gender, race, weight Emergency Medical Responder: First on Scene, 10/e Christopher J. Le Baudour | J. David Bergeron Copyright © 2016, 2011, 2009 by Pearson Education, Inc. All Rights Reserved

Patient Care Reports • Correcting Errors § Cross out incorrect item with single line, initial it, write correct number beside or above it. § Never completely cover incorrect information. • It may appear you are attempting to hide something. Emergency Medical Responder: First on Scene, 10/e Christopher J. Le Baudour | J. David Bergeron Copyright © 2016, 2011, 2009 by Pearson Education, Inc. All Rights Reserved

Figure 8. 3 An example of how to properly document an error in documentation. Emergency Medical Responder: First on Scene, 10/e Christopher J. Le Baudour | J. David Bergeron Copyright © 2016, 2011, 2009 by Pearson Education, Inc. All Rights Reserved

Think About It • The quality of your documentation is reflective of the care you provide. • How can data collection benefit EMS? • What elements would be essential to document for a refusal of care? Emergency Medical Responder: First on Scene, 10/e Christopher J. Le Baudour | J. David Bergeron Copyright © 2016, 2011, 2009 by Pearson Education, Inc. All Rights Reserved

Methods of Documentation • Paper forms § PCR forms filled out by hand • Computer-scan forms § PCR forms completed by hand § Fill-in-the-bubble format can be scanned into computer for information management and statistics gathering. Emergency Medical Responder: First on Scene, 10/e Christopher J. Le Baudour | J. David Bergeron Copyright © 2016, 2011, 2009 by Pearson Education, Inc. All Rights Reserved

Methods of Documentation • PDAs or handheld computers § Specialized software allows emergency care professionals to enter PCR information. § Information then downloaded to computer devices at hospital, base, or main office Emergency Medical Responder: First on Scene, 10/e Christopher J. Le Baudour | J. David Bergeron Copyright © 2016, 2011, 2009 by Pearson Education, Inc. All Rights Reserved

Methods of Documentation • Laptop computers § Software allows responders to complete PCR on computer and print from docking station or send wirelessly to hospital or central database. Emergency Medical Responder: First on Scene, 10/e Christopher J. Le Baudour | J. David Bergeron Copyright © 2016, 2011, 2009 by Pearson Education, Inc. All Rights Reserved

Figure 8. 4 A typical electronic tablet used for documenting patient care. Emergency Medical Responder: First on Scene, 10/e Christopher J. Le Baudour | J. David Bergeron Copyright © 2016, 2011, 2009 by Pearson Education, Inc. All Rights Reserved

Methods of Documentation • Data-enabled cellular devices § Advanced cellular data devices operate PCR applications to complete and send documentation quickly and easily from cellular phones. Emergency Medical Responder: First on Scene, 10/e Christopher J. Le Baudour | J. David Bergeron Copyright © 2016, 2011, 2009 by Pearson Education, Inc. All Rights Reserved

Think About It • How might electronic PCR be useful during an emergency with multiple patients? • What legal circumstances might require review of a PCR? Emergency Medical Responder: First on Scene, 10/e Christopher J. Le Baudour | J. David Bergeron Copyright © 2016, 2011, 2009 by Pearson Education, Inc. All Rights Reserved

Summary • Patient care documentation is important. § Continuity of medical care to legal proceedings § Becomes permanent part of patient's medical record § Can be used by EMS organizations to improve overall quality of emergency services continued on next slide Emergency Medical Responder: First on Scene, 10/e Christopher J. Le Baudour | J. David Bergeron Copyright © 2016, 2011, 2009 by Pearson Education, Inc. All Rights Reserved

Summary • PCR main categories § Run data § Patient data • Completed using combination of fill-ins, check boxes, and narrative areas continued on next slide Emergency Medical Responder: First on Scene, 10/e Christopher J. Le Baudour | J. David Bergeron Copyright © 2016, 2011, 2009 by Pearson Education, Inc. All Rights Reserved

Summary • Each PCR has a minimum data set as defined by U. S. Department of Transportation. • Documentation errors should be corrected without trying to obscure erroneous information. • Put a single line through mistake, enter correct information above or beside it, initial change. continued on next slide Emergency Medical Responder: First on Scene, 10/e Christopher J. Le Baudour | J. David Bergeron Copyright © 2016, 2011, 2009 by Pearson Education, Inc. All Rights Reserved

Summary • Patient care documentation completed § Traditional paper-based forms § High-tech handheld computers § Data-enabled cellular devices • Ensure accuracy and avoid subjectivity when documenting what happened on each response. Emergency Medical Responder: First on Scene, 10/e Christopher J. Le Baudour | J. David Bergeron Copyright © 2016, 2011, 2009 by Pearson Education, Inc. All Rights Reserved

Review Questions 1. What is the purpose of the PCR? 2. What elements are typically included in the PCR? 3. What are the tools used to complete documentation in the field? Emergency Medical Responder: First on Scene, 10/e Christopher J. Le Baudour | J. David Bergeron Copyright © 2016, 2011, 2009 by Pearson Education, Inc. All Rights Reserved

Please visit www. bradybooks. com and follow the Resource Central links to access content for this text. Emergency Medical Responder: First on Scene, 10/e Christopher J. Le Baudour | J. David Bergeron Copyright © 2016, 2011, 2009 by Pearson Education, Inc. All Rights Reserved