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Transcript
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-bysystem. 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 survey & Police notification
Documentation Checklist
Procedure
Possible
points
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Obtain demographic information
Clearly define chief complaint
Note initial level of consciousness
Define location/presentation
Obtain history of present illness
Perform complete physical assessment
Note pertinent positives
Note pertinent negatives
Note pertinent past medical history
Document allergies
List current medications
Record treatment
Record response to treatment
Place EKG strip. (ALS services only)
Document orders
Document times
Record vital signs
Complete Glasgow Coma Scale
Completed Trauma Score (if indicated)
Obtain appropriate signatures at receiving facility
Total Points
Points
awarded
20
COMMENTS:____________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
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PAPERWRK.DOC