Wednesday, August 8, 2012

EMS Patient Care Report Writing | Documentation 101 | Part 2 - Field Notes

Welcome to Part 2 in our continuing blog series “EMS Patient Care Reporting Writing/Documentation 101”. 
The Writing Implement
Before you do anything else at the beginning of your shift, make sure you always have a pen that writes (preferably one that writes at all angles and on just about any surface.)  There’s nothing more frustrating than to be on a run, reach for something to write with and find that you either forgot to grab a pen or you just didn’t bring one along.

Without a good writing implement, how are you going to record and remember vital signs?  How will you copy down meds and allergies?  Will you remember the time of onset of symptoms without writing it down?  What about the patient’s name and demographic information?  How are you going to record all this unless you can write it down.

Rest assured you’ll forget some key bit of information unless you write it down.

Oh and don’t’ forget, you’ll need a pen to obtain an authorization signature (we’ll cover this in a separate blog somewhere down the road.)

Something to Write On
The second most important item to include as a part of your uniform is something to write on.  I like to carry this little “flip” notebook that was given to me some time ago by one of the local hospitals during EMS week.  It simply has a little notepad inside (if you care not to order the refills, just stick in a simple pad of any type) protected by a nice leather cover and it slides into my side pocket quite nicely.

I’ve also seen some of my partners work with a metal mini-clipboard, which works nicely.  Or maybe your department has a field notes template page that you are required to complete in the field. 
Whatever device works for you, use it. 

Modern technology also can allow you to potentially keep notes on your smart phone, if you are so inclined.  Technology is great.   Just make sure that you save it and don’t erase it.  Some of you may work with electronic tablet/laptop devices in the field.  As long as it records the info you need it to record and you can call upon it back at the station to complete your PCR, then think out of the box and use your resources.

In the extreme, if you at least have a pen you can take notes literally on anything.  I’ve spent a few minutes in the shower rubbing the skin on my hand to get rid of info (no notepad? Skin works in a pinch.)  I’ve even used the surface of a rubber glove in the most extreme situations, but keep in mind…don’t throw the gloves away with your information!

What Info Needs to be Recorded?
So what do we need to be sure to record for later use when completing your PCR?

Here’s a bullet point list that I brainstormed to help you be sure you grab all the information possible from your ambulance run.  Collect this information by answering these key questions and writing those answers down to help you write your PCR later on after your incident has been completed…
  • How and by what authority was I dispatched?
  • Were there other responding units?
  • What emergency was our unit dispatched for?
  • What did my partner and I find when we arrived on scene?
  • What was the patient’s Chief Complaint? (more on this in a future blog)
  • What were the key incident events and the progression of the events? (Short notes to remind you should be recorded)
  • What are some things I need to remember about the scene itself?  (Such as the condition of the scene, inclement weather, barriers to patient care, presence of other responders, motor vehicle crash scene size-ups, etc.)
  • What signs and symptoms did the patient present with?
  • What were the results of my assessment(s)?
    • What were the important things I found on my primary…secondary…survey?
  • What treatments did we provide?
  • Did my patient worsen, improve or stay the same?
  • What prompted the patient/patient’s family to activate the EMS system today?
  • Who provided me with information about this run? (Patient’s family, friend, bystander, law enforcement, fire personnel, etc.)
  • What medications are being taken by my patient on a regular basis?
    • Did my patient take his/her medications today?
    • Is my patient allergic to any medications?
  • What are the mileage readings at each point of this run (ie. Out of Station, On Scene, At Receiving Facility, Back in Station)
  • Be sure to record the mileage to the nearest tenth of a mile as required by Medicare
  • What were the relative times connected to this run? (Record this assuming you do not receive any type of CAD sheet from your 9-1-1 system or in the case of non-emergency/routine transports where there is no 9-1-1 tracking from a CAD system.)
  • What is the patient’s demographic information (Name- minus nicknames, Date of Birth, Social Security Number, Insurance Information- again this assumes you will not be obtaining this information at a another time and from another source.)
Now It’s Up to You!
You’ve now made it through two parts of our documentation series.  We hope the picture has begun to make sense for you as we piece this puzzle of effective Patient Care Report writing together in easily understandable and manageable parts.  Feel free to print these blog postings and share with your friends.  If you have any questions, be sure to e-mail your contact here at Enhanced.  My e-mail address is chumphrey@enhancedms.com.

Let me know what this series is doing to help you become a better Patient Care Report writer.  E-mail me with any suggestions you may have for topics we can cover as part of this series.

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