Episode 10 - EMS Documentation and Communication

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EMS Documentation and  Communication

Released

September 2023

Hosts

John Hill

Scott Wildenheim

Caleb Ferroni

Guest

Jon Cameron

Product Links

https://sansio.com/

Episode Videos

Documentation and Data - Part 1

Documentation - Part 2

Documentation and verbal reports- Part 3

EMS Documentation Live Show- Part 4

Episode Audio

Show Notes

UH EMS Data Team

Jon Cameron

Mike Monahan

David Yash

Liaisons between Medical Control Departments and UH EMS

ePCR, Lifenet, Cellular, iPads, EMS Digital things

 

UH Standard template for charting in Health EMS

Departments can add to this, tailored to departmental needs


Documentation: Why? 


Clinical - Medical record that is part of the larger electronic health record for your patient. 


Legal - Source of record for lawsuit, insurance audit, medical review. It’s yours, you will need it in the event that you are asked to recall the event. 


Operational - Can be used to help determine regional or local resource needs. Drives decisions with allocation and protocol.


Financial - Billing uses the document for collections purposes


Pictures are worth a thousand words

Wounds, Med Lists, Home Medical Equipment, Abuse, Scene, Etc.

Do not save to camera app on device, use direct attachment in ePCR. HIPAA issue stored on local device, OK to be saved to the chart



Pt advocacy - continuum of care


Treatments/meds in Event log versus narrative:

Treatments in your software ask further qualifying questions pertinent to that procedure.


Data pulled from the event log is used locally and nationally. Locally we use this data to improve our standard of care including knowing what medications are being used (or not used), our treatment success rates. Etc.


Talk to text and proofreading - Verify patients name Use “ ” instead of spell check, 

Verify your patient, verify Hx meds allergies. SSN utilization


Treatment and meds in the event log will ask further qualifying questions, i.e. intubation, splinting, IO, RSI, 


If you start an IV do you document what the purpose of that IV was? Do you document why you did NOT start an IV?


Intubation - failure to ventilate, oxygenate, protect airway? Document all attempts including failures


Utilize the cardiac monitor events to documents treatment/meds


Collection of ETCO2 waveform, Intubation verification.


Attachments - Emphasize the importance of photos.


Narrative structure - Should start at the time of dispatch, Include a visual description of the patient's condition.  This initial impression and the documentation and that subsequent report to the ED is vital information. Use adjectives to qualify that condition. Use a patient quote when possible, especially in the Chief Complaint.


Keep subjective statements out of your narrative. (Family was rude to EMS)


Include HPI


“ACLS” followed alone, NOT appropriate. Describe the event. 


Narrative prompts=

>60% of transported patients have some sort of pain complaint. How do you address that pain? How do you document that pain? OPQRST. 10/10 “Patient's demeanor and actions do not match the patient’s stated pain scale”

How do you document your assessment?

We are trained professionals. We should document to a level that represents your professionalism. Steve Wirth of Page Wolfberg & Wirth says “the quality of your documentation reflects the quality of your service”


Print preview - shows how the chart will look to others once printed. 


Review your imported events to make sure you have quality information


“Vitals stable” Means nothing 


Review the V/S that were imported!

Signatures - Everyone who administers or wastes a medication should sign the ePCR.

Signatures - If the patient can only make an X in the signature box you must sign next to their X


IS MY DOCUMENTATION COMPLETE? Do not leave anything up for assumptions.


You have 24 hours to complete your documentation.


Exchanger - Electronic transfer of your PCR to the receiving facility. 

Physicians EXPECT to see your documentation in the patient's chart. 


Verbal Communication

Radio vs telephone prehospital report


Online Med control questions

I’m John, I am a first responder/basic/advanced/paramedic with Munson Fire. I would like to give Duoneb or lopressor for this reason. I have a 84 YOM with COPD, worsening SOB for 3 days, wheezing in all fields.


Use your name - value

What is important in report

Abbreviated report  - high points

“Suspect” “Believed” Do not just repeat the ECF’s reason for transport facilitating diagnostic momentum. Use your own differential


Bedside report

This is Barry, he is a 84 YOM who called EMS for 3 days of worsening SOB. He does not have O2 at home. Pt has been trying his nebulizer at home without any relief. Found hypoxic with SPO2 of 78% on RA, EtCO2 was 45. No fever. EKG showed sinus tachycardia. Started on 4L NC. Gave 2 Duonebs in route. With improvement.

The Protocols

Episode Shorts

From The Episode

Jon explains how changes can be made to a chart at any time if there are corrections that are needed

Caleb describes the largest fish he has ever caught

Jon clarifies the need for adding events in the event log

Scott practices carrying bushels of wheat