2004 EMS charting

Early documentation Lecture. Focuses on the days of written charts and SOAP, CHART, and other methods.

1. SOAP Made Easy
AKA: “You can stick that
pen….”
By Steve Cole, EMT-P
Ada County Paramedics

2. Revised Jan 2004 by
RSC
ACEMS
Topics
•Reasons for Documentation
•The Prehospital Care Report
•Legal Considerations
•Special Situations
•Enrichment

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RSC
ACEMS
Introduction
•The responsibilities of the EMT-Basic go
beyond the assessment, management, and
transport of a patient to the hospital.
•The EMT-Basic must also be able to
prepare a patient care report, to document
what was completed prehospitally should it
need to be reviewed at a later time.

4. Revised Jan 2004 by
RSC
ACEMS
Goals
•Write consistent and comprehensive
documentation of patient care contacts.
•Write in a form acceptable through out the
medical industry.
•Write charts in a legally defensible way.
•Write charts that demonstrate indications,
responses, and other pertinent information behind
interventions we do.
•Write charts that accurately tell the impact of
EMS on any pt contact.

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RSC
ACEMS
Basic Rules of documentation
1.BASIC "RULE" OF DOCUMENTATION:
"IF YOU DIDN'T WRITE IT, IT DIDN'T GET
DONE!"
2.THE PROFESSIONALISM OF THE REPORT
REFLECTS ON THE PROFESIONALISM OF
THE WRITER.
3.DOCUMENT THE SAME WAY EACH TIME
.

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RSC
ACEMS
Reasons for Documentation
•Medical Uses
–Helps to ensure continuity of care once the patient is
delivered to the Emergency Department
–Provides a baseline against which other care providers
can better gauge patient improvement or deterioration
–Allows clarity for future treatment plans as it avoids
duplication of interventions, and prohibits the
administration of care which was shown to be
ineffective

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RSC
ACEMS
Reasons for Documentation
•Administrative Uses
–Becomes a part of the permanent medical records
maintained at the hospital for the patient
–Can be used in the preparation of bills
–Can also serve as documentation for insurance
companies who request specific records

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RSC
ACEMS
Reasons for Documentation
•Legal Uses
–Although not themostimportant reason, one of the very
important reasons for documentation is that your record
may be used in legal proceedings.
–A run may have been the result of a crime, or the run
may result in a lawsuit. In either instance, you may
appear as a witness, and your testimony falls squarely
on what you have provided on the report.

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RSC
ACEMS
Reasons for Documentation
•Educational and Research Uses
–Can be used by researchers to demonstrate the
applicability (or lack thereof) of certain medical
interventions
–May be used to assess adherence of the EMT-B to local
protocol
–Integral part of ongoing quality improvement processes
–May help identify areas in which continuing education
may be warranted

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RSC
ACEMS
The Prehospital Care Report
•Prehospital Care Report (PCR)
–This is the major piece of documentation that EMS
providers must complete following an EMS call.
–Name of the PCR can vary according to locality; it is
also known as a “trip sheet,” “run sheet,” or “run
report.”
–The format can also vary according to local EMS
jurisdiction needs.

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RSC
ACEMS
Charting systems
•Effective and efficient charting has been an
issue to medicine throughout history.
•Numerous methods of charting have
evolved over time.
•More are evolving every day.

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RSC
ACEMS
Narrative Method
•A diary or story like approach to the
recording of patient care
•Are more efficient if used in combination
with flowsheets for recording some
repetitive data

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RSC
ACEMS
Narrative Method
Advantages:
•Good for triage systems, quick entries
•familiar to most nurses
–can be easily combined with other methods
•“P” in SOAP

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RSC
ACEMS
Narrative Method
Disadvantages:
•lack of structure
•task oriented and time consuming
•information may be difficult to retrieve
•does not always reflect critical thinking,
decision making and analysis

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RSC
ACEMS
CHART Method
A Problem Oriented method of charting
•C: Chief Complaint
•H: History (AMPLE)
•A: Assessment
•R: Rx (Treatments done)
•T:Transport (Events during transport)

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RSC
ACEMS
CHART Method
Advantages:
•Good as a format for verbal reports,
•Simple to remember
Disadvantages:
•Is not accepted outside of the EMS community
•Does not take into account other factors beside pt
care (like scene survey, etc)
•Not as comprehensive as other forms.

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RSC
ACEMS
Charting by exception
•Includes flowsheets, documentation by
reference to standards of practice,
protocols, a nursing data base, nursing
diagnosis based care plans and SOAP
progress notes

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RSC
ACEMS
Charting by exception
•Basically the Idea of charting only
exceptions to the norms
If the lungs are clear and equal, then it doesn’t
get charted.
•Requires a defined set of “norms” to
function correctly
•Gained popularity but is now dissapearing.

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ACEMS
Charting by exception
Advantages
•Quick and easy
•Very little time involved.
•Provider friendly.
Disadvantages
•can require duplication of charting
•Does not accurately paint a picture.
•may impact reimbursement
•Poorly defensible

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ACEMS
SOAP charting
A problem oriented charting method
•Subjective data
•Objective data
•Assessment
•Plan

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ACEMS
SOAP Method
•Has been expanded in NURSING to
include
–SOAPIE
•add Interventions
•add Evaluation
–SOAPIER
•add Revision

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RSC
ACEMS
SOAP Method
Advantages:
•well structured
•reflects the care process
•easier to track particular problems for QI
•can be used effectively with standard careplans
•frequently used in the integrated plans
•Is used through out the medical and billing
community.

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RSC
ACEMS
SOAP Method
Disadvantages:
•requires rethinking documentation process
•can be redundant
•not the Quickest
•has met some resistance

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RSC
ACEMS
At Ada County EMS we have
implanted a computer charting
system , but we still write a
SOAP note with in the system.
This gives us good defensible
charts while retaining data
management and QA functions.

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RSC
ACEMS
You are required to use the SOAP format
on all charts you do for this class.
ACEMS

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RSC
ACEMS
WHAT IS THE
SOAP?

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RSC
ACEMS
SUBJECTIVE
•EVERYTHINGyou find out about the pt
from something other than direct
observation/Assessment
•Information from the pt.
•Information from the PD
•Information from the Chart (Exception:
some diagnostics)
•Information from other medical providers
prior relating to care prior to your arrival

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RSC
ACEMS
Dispatch Information
•Keep separate from main body of the SOAP, still
important.
•Very important with multiple pt’s.
•“Medic 1 dispatched to MVC. On arrival
presented with multiple patients, this is pt 2 of 4
seen by this unit.”
•Be sure you coordinate with other providers so
your numbers match up.
•Good place to document delays, wrong
directions, etc.

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ACEMS
S: “once upon a time”
•Your opening lines can make or break a
subjective
–Pt. Age, C/C or reason why they were unable
to present one.
–Followed by Secondary Chief complaints.
•“Pt is a 31 y/o male with c/c of lower back
pain secondary to fall. Pt also complains of
SOB, Nausea, and dizziness”

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ACEMS
S: Quotes
•Pt States: Exact verbage
•Pt reports: summery
•Guess what ... if the patient has a potty mouth
and this disposition or information is important
to the situation, go ahead and include the
quotes, but don't forget quotation marks!
•Don’t use vulgarity when it doesn’t “add”
anything to your documentation.

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RSC
ACEMS
S: OPQRST
•Very Important when describing any type
of Pain.
•Can be used very effectively for other
types of discomfort (chest pressure,
tightness, etc) and complaints (nausea,
vertigo, etc)

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RSC
ACEMS
S: OPQRST” Pain
Questions
–Onset -when start, sudden or gradual. Activity at
onset.
–Provoke -position, movement, local or general
–Quality -sharp, dull
–Radiating -if so, from where to where
–Severity -mild-moderate-severe or scale of 1-10
–Time -how long, continuous or intermittent, worse
or better. Crescendo pattern.

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ACEMS
S:Previous episodes
•Prior episodes, what brought it on?
•Seen By an doctor?
•Self or prescribed treatment (w/ or w/o
success)
•Crescendo pattern?

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ACEMS
S:Pertinent positives and
negatives
•Depends on c/c
•Very important
•Can protect you or open you up
•Common ones : Chest discomfort, SOB,.
N/V, Near syncopal episodes, dizziness,
previous episodes.

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RSC
ACEMS
OBJECTIVE
•“Just the facts maam.”
•Clinical, objective,
non judgmental
•Think scientific
•Think MR. Spock as a
paramedic.

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RSC
ACEMS
O: VEHICLE DAMAGE/SCENE
SURVEY
•General hygiene of area
–Food in fridge, Garbage overflowing, fecal matter on
floor or in bed.
•Vehicular damage (or lack there of)
–Points of impact, distance from road, windshield
starring, steering column damage, etc.
•Pill bottles, drug paraphernalia
•Crowd/safety issues.

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RSC
ACEMS
O: The Pt
•Who is with the pt
–PD, Nurse at bedside, family, bystander, little green
men
•Position of the pt?
–Recumbent, supine, simi-fowlers, standing
•Interventions in effect?
–O2, IV ,C-collar, Manual C-Spine,
–“Stare of life”
•What is the pt doing?
–Walking, Running, Fighting, yelling, gurgling,
tripoding

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RSC
ACEMS
O: LOC
•LOC is the most important descriptor in the
primary survey, as it will be examined closely in
DWI cases, mental holds, criminal prosecution,
etc.
•Conscious , alert, oriented to person , place, time
(x3)
•Cooperative
•Mental affect, demeanor
•Short vs long term memory
•Cognition

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RSC
ACEMS
O: Primary Survey, rapid
survey, etc…
Examples
•LOC: Mentation, described before
•Airway: Clear, snoring
•Breathing: Labored, Non labored, retractions,
grunting, speech dyspnea, audible wheezes
•Circulation: Skin pallor, distal pulses quality
•Disability: Mini nuero, left sided deficits, slurred
speech, unstable gait, moves all ext well.

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RSC
ACEMS
O: Head to toe
•HEENT:
•NECK/BACK:
•CHEST:
•ABD:
•PELVIS/LOWER EXT:
•UPPER EXT:
•NEURO: Detailed Neuro (optional)

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RSC
ACEMS
O: Diagnostics
•Blood Glucose: State source (IV stick,
capillary blood)
•Pulse OX: before and after O2 or BVM,
neb, etc
•EKG/ 12 lead (if you are qualified to read,
may be cosigned by medic )
•Temp: Oral, axillary, rectal, etc
•ETCO2.

42. Revised Jan 2004 by
RSC
ACEMS
Assessment
•Field Diagnosis
•No “red swollen deformed extremities”
–Call a Fx a Fx!
•R/O, Rule Out: Cop Out
•Possible, probable etc are looked down on for billing
purposes, but may be used if you don’t bill.
–OK as a supplement to a DX “Altered Mental staus ,
probable herion overdose”
•Chronic problem that got worse? : “exacerbation of”
•VS.
•Try to have at least two diagnosis

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RSC
ACEMS
Assessment continued
•Syndromes are a collection of symptoms;
–Hyperventilation syndrome
•Diagnosis of exclusion
–Dx made only after all other things have been
ruled out. Common pitfall, be very careful
–Alcohol intoxication,
–Anxiety, Psuedo-Seizure
–Muscular neck pain

44. Revised Jan 2004 by
RSC
ACEMS
A: Common assessments
•Soft tissue injury secondary to fall
•Pleuratic pattern Chest wall pain
•Ischemic pattern Chest pain
•Syncope/near syncope of unclear origin
•TIA , CVA with left sided deficits
•Multi system trauma
•Hypoglycemia (may add resolved)
•Post Seizure, Active Seizure , Status epilepticus
•Altered Mental Status-Probable Heroin Overdose

45. Revised Jan 2004 by
RSC
ACEMS
The PLAN
•Chronological detail of pt contact beginning with
on scene. Use time notations.
–Exception: may place pert . Info to call that occurred
and caused a delay to pt contact, like dispatch error,
ect.
–“(2030) On scene, contact delayed secondary to scene
sfety issues. EMS staged.
–“(2040) Pt contact and assessment”
•Use 3
rd
person.
•Both Subjective and Objective.
•Itemize

46. Revised Jan 2004 by
RSC
ACEMS
P: Interventions
•Time?
•What?
•Who?
•How Much?
•Response/adverse effects? OBJECTIVE and
SUBJECTIVE.
•Why?
•“(2031) Oxygen applied by S. Cole for SOB at 10 LPM
NRB mask with pt reporting some relief. Pt work of
breathing decreases.Chest pain decreases to 4/10.”

47. Revised Jan 2004 by
RSC
ACEMS
P: Reassessments
•Document reassessments to justify doing or with
holding interventions.
•“(2035) Reassessment finds increased work of
breathing, decreased tidal volume, and pt
unresponsive. Sats decreased to 66%”
•“(2035) NRB mask changed to PPV via BVM
with 30 fr. OPA by S. Cole with Sats increasing
to 90%.”

48. Revised Jan 2004 by
RSC
ACEMS
P: Critical Events
•Critical events that do not fall into other
categories are still documented
chronologically.
•(2038) RN on location presents EMS with
a valid Comfort One DNR (#xxx).
•(2038) Pt’s Mother on scene, becoming
violent , restrained by PD, requiring EMS
to relocate pt to MICU”

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RSC
ACEMS
P: refusals
•“Risks explained”
•“transport options discussed”
•“Pt deciles transport”
•“Informed refusal of services”

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ACEMS
P: End of call
•Transfer of care: “Report to XXX” “Pt left on
scene with PD.
•Belongings: “all paperwork, purse (with
undisclosed contents) and other belongings at
bediside (to EMS staff, etc.).”
•Pt condition on d/c: “Pt alert , oriented, calm, and
in no apparent distress” “Pt tearful, tachypniec,
and yelling at EMS on clearing”.
•HIPAA and/or billing completed?

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ACEMS
P: After notes
•Itemizing of :
–Drugs
–ET attempts
–Shocks
–Etc
•Other facts.

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ACEMS
The Patient Care Report (PCR)
•PCR Formats
–Most traditional is the written report.
•Series of check boxes, and lines for writing a narrative section
–An alternative is the computerized report.
•May include completion of a paper version that is scanned into
a computer
•Personal Digital Assistants (PDA) are another format gaining
popularity
•PCR documents using some type of computer interface usually
allow for spell checking and enhanced statistical gathering
capability

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ACEMS
The Prehospital Care Report

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ACEMS
The Prehospital Care Report

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RSC
ACEMS
The Prehospital Care Report
•PCR Data
–Information provided on the PCR should give a clear
and accurate picture of what occurred in the prehospital
environment.
–There are two basic rules to follow:
•“If it wasn’t written down, it wasn’t done.”
•“If it wasn’t done, don’t write it down.”

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RSC
ACEMS
The Prehospital Care Report
•Minimum Data Set
–Information requested by the U.S. DOT that should
appear on every PCR.
–Allows for more complete data entry on each run.
–Promotes more even comparison and analysis of data
from across the United States.
–More information may be included on the PCR
according to local needs, but above all, the minimum
data set must be present.

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RSC
ACEMS
The Prehospital Care Report
•Minimum Data Set
–Patient information gathered by the EMT-B
•Chief complaint
•Level of responsiveness (AVPU) –mental status
•Systolic blood pressure for patients over 3 years of age
•Skin perfusion (capillary refill) for patients less than 6
•Skin color and temperatures
•Pulse rate
•Respiratory rate and effort

58. Revised Jan 2004 by
RSC
ACEMS
The Prehospital Care Report
•Minimum Data Set
–Administrative information
•Time the incident was reported
•Time the unit was notified
•Time of arrival at the patient
•Time the unit left the scene
•Time the unit arrived at its destination (hospital, etc.)
•Time of transfer of care

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ACEMS
•General Completion Guidelines
–Completely fill out form in its entirety.
–Strike through empty (unused) sections.
–Preferably use black ink.
–Use proper spelling and
sentence structure.
–Use only approved medical
abbreviations.
-Document Response to Tx’s
–Be thorough and systematic.
The Prehospital Care Report

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ACEMS
Don’t forget the boring stuff
•Administrative
Information Section

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ACEMS
Billing Info
•Patient Data Section

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ACEMS
The Prehospital Care Report
•Vital Sign Section

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ACEMS
Legal Concerns
•Confidentiality
–Must exercise great discretion when handling
any information about a patient; everything you
enter on the PCR is confidential.
–Generally, you can provide information to other
health care providers who need it for
continuation of care.
–Any other use has to follow appropriate, legal
channels before it can be disclosed.

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RSC
ACEMS
Legal Concerns
•Refusal of Treatment
–Any competentadult can refuse treatment.
–Your responsibility is to be sure they are making an
informed decision.
•Perform a complete assessment.
•Make repeated attempts to persuade patient agreement.
•Inform patient clearly why he needs to go, and what could happen if
he does not.
•Consider contacting medical direction prior to your departure.
•Complete PCR and refusal section, have patient sign, and then
someone should witness signature.
•Try to arrange alternative transport if possible.

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ACEMS
Legal Concerns

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ACEMS
Legal Concerns
•Falsification
–PCR meant to be thorough and accurate record.
–Document exactly what happened regarding
patient assessment and management.
–Acts of omission or commission may lead to
suspension, revocation of certification, or even
criminal charges.
–Most importantly, falsification compromises
patient care.

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RSC
ACEMS
Legal Concerns
•Correcting Errors
–Any error should have a single line drawn through it,
along with the correction noted and the initials of the
person completing the PCR.
For this class, a Maximum of THREE errors (initialed
and corrected) are allowed prior to re-writing the
chart.

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RSC
ACEMS
Special Situations
•Multiple Casualty Incidents
–In situations of an MCI, the need to treat and
transport multiple patients may take precedence
over PCR completion.
–Each EMS system has within its MCI plan a
mechanism by which the most important
information regarding the patient is passed on.
–Commonly “triage tags” are used for this
instance.

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RSC
ACEMS
Special Situations
•Special Reports
–Documentation reports which the EMT-B may have to
complete given the particularities of the EMS event:
•Any “Mandatory Reporting Situation”
•Suspected abuse of pediatrics or geriatrics
•Exposure to infectious diseases
•Injury to an EMS team member
•Unusual situation which the EMT-B feels might require special
documentation and/or the informing of another agency

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RSC
ACEMS
Final thoughts
•Use protocols, articles, medical text books to be
sure you cover all points in a medical complaint
•Use medical dictionaries frequently
•Document in third person.
•Use a set format, each and every time that covers
all facets of pt care.
•ALWAYS BE SURE YOUR RECORD DOES
NOT CONTRADICT ITSELF