It probably doesn’t surprise anyone that patient assessment is a crucial skill set when it comes to evaluating and treating patients at all levels of EMS care. Perhaps less recognized but just as important is communication. Communications competencies include accurate documentation of a patient care report (PCR). There are five functions of an EMS PCR:
- communicate with other healthcare providers
- billing requirements
- quality assurance/improvement
- research
- legal defense
Even though the first four are essential, I want to focus on the last, which needs defending in instances in which you might lose your certification as an EMS provider. It doesn’t matter whether you write a PCR or do electronic charting (ePCR).
What to document
“If it wasn’t written, it wasn’t done” couldn’t be any more accurate in this realm. Document everything that you observe and do.
Pertinent negatives need to be evaluated and documented. If you ask your patient whether he/she was or is presently nauseous, and he/she denies in either case, it’s an important finding and must chart in your PCR: If negative nausea isn’t in the report, the conclusion is that you didn’t inquire.
PCRs need to be consistently written in the same format or style for every incident, whether it’s a cardiac arrest or a cut finger. Must the documenting of a patient’s refusal report be better than a motor vehicle accident? No. Both need a systematic approach and documentation to prove a complete task and comprehensive assessment.
There are several ways to maintain consistent documentation skills. The acronyms that follow are two examples:
Chief Complaint Subjective
History of Illness Objective
Assessment Assessment
R (Rx) Treatment Plan
Transport
Chief Complaint derives directly from the patient. For example, you find a patient who is sitting in a chair and holding his/her chest who states, “I have chest tightness, which started while I was running.” You document that you found the patient sitting in a chair who appeared to be in moderate distress and complained of “chest tightness” starting as he/she was running today. Don’t change the verbiage to state “chest pain” or “chest pressure.” Each could mean something different, lending to different diagnoses.
Subjective is the chief complaint and history of illness (present) and other information that’s obtained through an interview process, either directly from patient or family/friends.
Objective is physical findings, such as vital signs. A global assessment must be done and documented, including differential diagnosis and questioning pertinent positives and negatives.
Your Plan, R (Rx) Treatment and Transport must be detailed, including the patient’s change in condition (stayed the same, improved, got worse).
Document only facts that you observe or are spoken. Never put your opinion in a PCR. For example, “alcohol on breath” isn’t appropriate, and “appears to be drunk or under the influence of alcohol” must never be included in a report. Conversely, a staggering gait, slurred speech or the like should be stated. Many medical or traumatic conditions can present these symptoms.
Incomplete or missing information is essential, such as documenting ALS versus BLS assessment and treatment. Just because an elderly patient’s chief complaint is chest pain, where an EKG wasn’t performed and transported BLS to a hospital, you can’t justify this as ALS and bill for such. Documented service and level provided never should exist: You and your service lose credibility, and you always will get in trouble in court
Time and validation
Be careful of electronic timestamps for treatments on an ePCR. Inputting several different treatments together will give you the same timestamp. You must ensure that your treatment modalities flow; don’t let your ePCR dictate times. If you perform several vital signs, they each must be documented. Never do one set and chart two, falsifying your report, which is illegal.
Signatures from all EMS providers, the patient and an RN or doctor in the emergency department (ED) are necessary. The ED staff signature ensures proper patient transfer. (One EMS service left a patient in the waiting area; an hour later, the patient was found dead by hospital staff. The EMS service became implicated in a wrongful death suit.) Each EMS provider should review the PCR for accuracy and completeness.
Your PCR is a legal document that must be accountable in court. Can you defend your actions and charting? A step-by-step process is necessary for every PCR that’s written.
Your job isn’t finished until paperwork is complete: accuracy and accountability for everything done, keeping things out that don’t deal with patient care.
