EMS Documentation

EMS documentation

1. Documentation

2. Documentation Purposes Four major purposes for good, accurate documentation Clinical Legal Operation/Compliance Financial

3. Documentation Purposes Four major purposes for good, accurate documentation Clinical

4. Documentation Purposes Clinical Paints an accurate picture of what transpired Patient presentation Assessment History Treatment Continuum of care

5. Documentation Purposes Four major purposes for good, accurate documentation Clinical Legal

6. Documentation Purposes Legal Accurately records information for possible litigation in the future Litigation between parties Litigation against EMS DeTarquino vs. The City of Jersey City

7. Documentation Purposes Legal DeTarquina V. Jersey City EMS In the case of  DeTarquino v. Jersey City EMS, an Advanced Life Support (ALS) crew transported a patient who had been injured during an assault to a local community hospital, they were evaluated and then discharged. The patient later experienced a grand mal seizure and, after EMS was called again, was this time transported to a trauma center. The patient subsequently went into a coma and died of an intracranial bleed.

8. Documentation Purposes Legal DeTarquina V. Jersey City EMS The patient’s family brought suit, alleging that during the course of treatment and transport by the first EMS crew, the patient had vomited, but the crew had negligently failed to document that fact on their PCR. The lawsuit alleged that this documentation oversight was critical, because documenting the fact that a head-injured patient had vomited could be a sign of a potentially serious head injury, and had it been documented, the initial hospital would not have discharged the patient. The Court of Appeals agreed, finding that allegations of negligence  specific to EMS documentation  can be stated separate and apart from allegations regarding negligent patient care. As a result, the court ruled that the qualified immunity for acts of negligent care  do not  protect EMS caregivers when it is alleged that their  documentation  was negligent. In short, this case cautions us that there is a separate and distinct standard of care for EMS documentation, and that your documentation can be negligent even when your patient care is not.

9. Documentation Purposes Legal DeTarquina V. Jersey City EMS Patient vomited in presence of providers EMT’s didn’t pass on the fact he vomited Narrative included notation (–N/V) Crews were found negligent, not in their care, but in their documentation of care Appellate court determined that while EMS was provided immunity of liability for civil penalties, this only covered the act of care, not the documentation that follows. They opined that while the direct care involved more difficulty to perform than by a physician in a hospital, but the resulting documentation doesn’t involve that difficulty, therefore, it isn’t covered under the NJ qualified immunity statute.

10. Documentation Purposes Legal Accurately records information for possible litigation in the future Litigation between parties Litigation against EMS DeTarquino vs. The City of Jersey City Henslee Vs. Provena Hospital

11. Documentation Purposes Legal Henslee V. Provena Hospitals In yet another case,  Henslee vs. Provena Hospitals , the court found that numerous documentation deficiencies — including a crew’s omission of failed intubation attempts — constituted evidence of deviation from their clinical protocols, which rose to the level of gross negligence .  This case tells us that sparse or poor documentation — including notable deficiencies of issues that should be addressed in a PCR (like all treatments and interventions provided or attempted, even if unsuccessful) can deprive EMS providers of the defense of qualified immunity and directly lead to liability. https://casetext.com/case/henslee-v-provena-hospitals

12. Documentation Purposes Legal Started having an anaphylactic reaction after eating Chinese food Peanut Allergy Husband drove to Intermediate facility, physician immediately called 911 for transport. At facility – 1652, 911 called at 1653, arrived at 1656, left at 1712, at hospital – 1725 Classified “load and go” but stayed on scene for 16 minutes Multiple disagreements EMS states jaw was clenched and physician stated it wasn’t and he placed an oral airway without difficulty EMS states they gave 2 doses of epi, but no documentation of administration States patient was obese, but family disagrees

13. Documentation Purposes Legal EMS states jaw was clenched and physician stated it wasn’t and he placed an oral airway without difficulty EMS states they gave 2 doses of epi, but no documentation of administration States patient was obese, but family disagrees Successful on third intubation attempt, but arrival at hospital patient was cyanotic and confirmed tube was in esophagus “He said/She said” Discrepancies in care stated vs documented EMS states they gave 2 doses of epi, but not documented Didn’t give etomidate with no documentation as to why ETT was found to be in the esophagus upon arrival, nothing documented confirming placement

14. Documentation Purposes Legal Accurately records information for possible litigation in the future Litigation between parties Litigation against EMS DeTarquino vs. The City of Jersey City Henslee Vs. Provena Hospital Browning vs. West Calcasieu Cameron Hospital Refusal of care

15. Documentation Purposes Legal Browning vs. West Calcasieu Cameron Hospital A court invalidated a signed patient refusal of care form because the crew had not taken the time to explain to the patient the risks of refusing care. In that case, a woman had refused care, despite showing signs that could have indicated a potential myocardial infarction (MI). The crew minimized the patient’s symptoms, saying that she was probably “minding the heat,” and obtained a signature on their refusal form. Since the court found that the crew failed to apprise the patient of the risks of refusal, however, the release of liability language on the refusal form did  not  protect the EMS providers. https://casetext.com/case/browning-v-west-calcasieu ?

16. Documentation Purposes Legal Background On June 1 , 1999 Ms . Browning traveled into Lake Charles, La with husband to see a movie and visit family Complained of left shoulder and arm pain – refused to go to hospital due to “its just bursitis” Saw movie, visited first daughter, on way to second daughter had a burger and soda from Burger King. Took walk around neighborhood with daughter, on way home told daughter that she didn’t feel well, at home states she felt “hot and weak”. Refused to have daughter call ambulance, until she vomited at 7:28, then daughter called anyway.

17. Documentation Purposes Legal First Ambulance visit Two paramedics – one “taking the lead” and doing most of interaction, but both “working as a team” Run sheet stated they were called for syncope with nausea and vomiting Present Finding: Upon arrival found 57 year-old caucasian female seated on couch. Noted vomitus on floor. Patient stated had eaten burger from Burger King approximately one hour prior to going for a walk. Patient denied any chest pain or any medical history. Patient stated that when she returned to the house, she became dizzy, light-headed, and nauseated. Husband stated he assisted her to the floor in kitchen. Patient's skin cool and diaphoretic [or sweaty]. Patient AOX3. Patient stated she felt she was fine after vomiting. Blood pressure was taken[.] . . . Patient again stated felt fine and refused transport to hospital for evaluation. Family alleges patient told them she “was having a hard time breathing”, and they were told about left arm and shoulder pain earlier.

18. Documentation Purposes Legal After assessment and gathering history, patient was told that she was probably having a heat related issue Patient told them that after vomiting she felt better, daughter reports noticing her face was pale. Paramedics kept telling her “You’re going to be alright, Ms. Browning” Asked for permission to transport patient to hospital, patient refused transport, unsure how many times they asked, but patient clearly refused all attempts made to transport her by paramedics. Patient signed refusal and paramedics left.

19. Documentation Purposes Legal Second Ambulance Visit Paramedics left, family assisted her to bathtub to help with “heat related” illness. Patient helped to couch after bath, then started gasping for breath and shaking. 911 reactivated. Same crew responded at appx 800 (presumed PM) Present Finding: Upon arrival found 57 year-old caucasian female lying supine on couch pulseless [and hardly breathing]. No CPR in progress. Patient had been dizzy and nauseated earlier this evening. Patient moved to the floor. Cardiac monitor shows ventricular fibrillation. Patient is pale and [sweaty] but warm. Negative abdomen distention. Patient is incontinent. Pupils equal at four millimeters and non-reactive. No available history or findings at present.

20. Documentation Purposes Legal Patient was worked following protocols, patient was pronounced dead at 0400 hrs the next morning. Crew was found to not fall under the immunity statute and didn’t follow protocols because refusal wasn’t properly filled out and explained. Refusals are required to be filled out, read to the patient and then signed.

21. Documentation Purposes Legal I admit that the above refusal is against the advice of the personnel of West Calcasieu Cameron Hospital Ambulance Service  who have advised me of the dangers which may result from my refusal  including, and not limited to the following: ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ ___. I realize that my refusal may cause or increase danger to myself or the patient. Nevertheless, I assume the risk and accept the consequences of my refusal. Furthermore, I do forever release and give up any claim, demand or action against West Calcasieu Cameron Hospital Ambulance Service, and any and all persons employed by or responding with any fire unit, rescue squad, police or ambulance unit, and do hereby covenant and agree to hold such persons and entities harmless from any claim, demand, loss or action, by myself, the patient, or any person claiming by or through myself or the patient for any alleged act or omission in the care or treatment of the patient in compliance with the refusal.  This release is binding on my heirs, executors, and assigns.

22. Documentation Purposes Legal In the blank section Crew member wrote  "Advised to suck on ice chips, take a tepid water bath to cool down and relax.“ Later this was added  "Possible heat related disorder versus syncope of unknown etiology versus possible cardiac problem.“ One crew member stated this was written after she signed the refusal, the completing crew member stated it was included prior to signing. Admitted it wasn’t read word for word, didn’t recall advising her it could be life threatening, didn’t recall telling her it could be a heart problem When asked if they tried everything to convince her to go, one medic responded with “ It is not my job to convince you. All I'm there . . . to do is to inform you of the possible injury or medical condition that you have. And if you are coherent enough and you can make your decision . . . it's your decision whether you consent to . . . [being] treated and transported.” When husband asked if patient was recommend to be transported, He stated “they didn’t recommend it, they just asked if she wanted to go”

23. Documentation Purposes Legal Previous cases found and copied from the following sources https://www.zolldata.com/blog/lessons-learned-from-ems-documentation-legal-case-studies https://casetext.com/case/henslee-v-provena-hospitals https://casetext.com/case/browning-v-west-calcasieu ?

24. Documentation Purposes Four major purposes for good, accurate documentation Clinical Legal Operation/Compliance

25. Documentation Purposes Operational/Compliance Data Collections/QA/QI Type of Calls How they happened Clusters of Diseases Emerging illnesses Quality Assurance and improvement Compliance with state and local policies/procedures

26. Documentation Purposes Four major purposes for good, accurate documentation Clinical Legal Operation/Compliance Financial

27. Documentation Purposes Financial Billing/Revenue Recovery Pays Paycheck Quality Equipment Improved Equipment

28. Documentation Purposes Financial Billing/Revenue Recovery 72 hours 7 days Longer we wait the less of a chance we will be successfully collecting. Above a certain amount recovered, comes directly to our budget. Recovered almost $1,000,000 last year Average transport is billed $1000.00 If we lose 10 billable call sheets a month due to not correcting that is $120,000 a year we could use for new trucks, uniforms, equipment.

29. Recipe for Good Documentation Accuracy

30. Recipe for Good Documentation Accuracy Correct Date Correct Times Correct Incident Number Correct Address Correct Name Correct treatment

31. Recipe for Good Documentation Accuracy Completeness

32. Recipe for Good Documentation Completeness Ensuring every relevant box is complete Ensuring all treatments are properly documented Ensuring MRN is obtained Ensuring all signatures are obtained and properly documented

33. Recipe for Good Documentation

34. Recipe for Good Documentation Narrative Thorough Narrative Paints an accurate picture Includes pertinent negatives Documents why you did, and why you didn’t provide a treatment

35. Recipe for Good Documentation

36. Recipe for Good Documentation Spelling and Grammar Ensure all spelling is correct Ensure you are using correct grammar Spell check and Grammar check should be used

37. Documentation Examples Good and Bad D - 3 vehicle accident, no entrapment reported, on Cople Hwy A - 3 vehicle accident across roadway, blocking all lanes. All patient out of the vehicles. Patient is a 74 yof standing in field complaining of left shin pain. C - Patient complaining of left shin pain following an MVC, with minor damage to her vehicle. H - Patient was restrained front seat passenger of vehicle that struck another vehicle with the driver front corner, minimal damage with no interior intrusion, no windshield damage, no seat damage. Patient only complaining of pain to left mid shin, with small abrasion noted. Patient states she didn't hit her head, had no LOC, was able to self extricate from vehicle. Patient refusing to be transported to hospital at this time.

38. Documentation Examples Good and Bad A - ATF 74 yof standing beside vehicle, Patient AAOx4, ABC's intact, GCS - 15. Patient has complaint of pain to left leg following an MVC. Patient pupils PEARL, skin - normal, warm, and dry. Patient has symmetrical facial features with no slurring or droop noted. Patient has no noted or reported pain or trauma to head or neck. Patient C-spine palpated, with no stepoffs or deformities. No pain either. Patient speaking in full sentences, with no signs of respiratory distress, no JVD. Lung sounds clear. No pain or trauma reported to chest or abdomen. Patient back and remainder of spine palpated, with no abnormalities noted. Patient denies any pain to thorax or abdomen. Patient has good PMS to all extremities with only an abrasion noted to mid left shin, where she is feeling pain. R - Assessment done, V/S obtained and noted. Ice applied to shin. Patient refusing to be transported to hospital. Patient was advised of the limitations of our examination, and that we can not tell her that she is fine, and that we advise her to be evaluated by a doctor. Patient states she understands, and is aware of the risk of refusing transport, with worsening of condition, up to and including death. Patient states she understand. Patient was told that if anything changes, she starts feeling worse, or is unable to bear weight to the leg, then she needs to get evaluated. She states she understands, and signed refusal. T - Patient refused transport.

39. Documentation Examples Good and Bad Medic 9-4 was dispatched to Street for a fall. Westmoreland advised that the patient was a 73 year old female that had fallen off of her couch, had some bleeding, and was currently still in the floor; Medic 9-4 marked direct with the information. Medic 9-4 arrived on scene to enter the residence and find the patient kneeling in front of her couch, with her arms resting on the couch. Crew approached the patient and asked about her chief complaint. Patient stated that she had recently had surgery on her arm, fallen off her couch and now was unable to get up out of the floor. She was asked if she was experiencing any head neck or back pain; she stated no. Crew asked the patient if she was experiencing any pain and she stated yes, she was then asked where the pain was located. Patient said that the pain was in her right upper arm and was around her scapula. She said that with her kneeling in the floor it was putting pressure on her arm. Crew tried to devise the best course of action to assist the patient to her feet. Patient was then asked if with assistance, would she be able to sit flat on her butt to which she replied yes. She proceeded to put herself in a sitting position. Once in the sitting position, steadied the patient under her left arm, as steadied her by her waist, patient was assisted into a standing position. Patient's son then helped the hold the patient in the standing as retrieved the patient's walker to sit behind her so she could sit.

40. Documentation Examples Good and Bad After the walker was in place, patient was told that she could sit straight down; patient was seated. Crew then began to assess the patient and asked her what happened. Patient, AxO X4, stated that she was reaching for her cup of juice when she fell, hit the left side of her and body, and then rolled and hit her right arm on the floor. Patient's left side (face and arm) were assessed and there were no obvious signs of injury/ deformity. asked if the patient had hit her head, and she replied no. Patient was anxious and concerned about her right arm. She was asked if she would like to be transported to the hospital via medic unit and she was unsure if she wanted to be transported. Patient had become increasingly anxious and asked if the crew could assist her to the couch as it was more comfortable than her walker seat. Her walker was placed next to the couch, she was assisted to her feet, and she sat down on the couch.

41. Documentation Examples Good and Bad As the patient sat on the couch, she began to become increasingly anxious and stated that her arm hurt. would coach the patient's breathing and she would relax. With the patient relaxed, she was asked again if she would like to be transported to the hospital and again stated no. retrieved the stretcher from the unit and stayed with the patient. Patient was asked a series of questions to determine her level of decision making capabilities. returned with the monitor, patient was placed on it ( bp cuff, pulse ox., 12-lead), and a baseline set of vitals was obtained. All vitals were within normal ranges and 12-lead was interpreted as a sinus rhythm. Patient was asked a final time if she wanted to the be transported to the hospital; she responded no. She was told that if her condition changed or did not improve, not to hesitate to call 9-1-1. Patient was then asked to sign a refusal form and obliged. Patient's son was also asked to sign as a witness to the refusal; he also obliged. Medic 9-4 cleared the scene and returned to service.

42. Documentation Examples Good and Bad D: Dispatched priority 1 with Fire for the unresponsive patient. M9-3 responded from quarters, and Capt. 9 responded from EMS Station 4. A: M9-3 arrived on scene to find fire department personnel already assessing patient with lone family member at bedside. Patient found alert/responsive, breathing normally, and with no immediate life threats noted at this time. C/C: Unresponsive (Reported) / Lethargic (Witnessed) Hx /HPI: Patient is a 90yof who has an extensive medical history known to EMS to include dementia, prior stroke, and diabetes. EMS is familiar with this patient, and patient is found at normal baseline known to this EMS crew. Patient's normal family caregiver is not bedside, and patient's remaining family member on scene states that she has called 911 to check on the patient because she is "not waking up" today like she normally does. Family member is also concerned fur to a recent medication change, and wants to be sure that the patient is not having an adverse reaction to the medication " Olanzepine " which she has been taking for the past 3 days. Patient is found to be easily rousable by EMS, and passes all field diagnostic tests, to include neuro/stroke assessment (VAN negative, BEFAST negative), vitals check, and blood glucose check. Patient answers AO-status questions appropriately, and is able to follow commands. Patient verbalizes that she does not want to go to the hospital, and that she is fine. No further history/HPI noted at this time.

43. Documentation Examples Good and Bad A: Patient is found AOx3/4 (not oriented to time; this is normal baseline for this patient due to dementia history). Patient's breathing is normal/non-labored, airway patent, lung sounds clear and equal bilaterally. Skin normal, warm, dry, and intact. No signs of trauma/DCAP-BTLS noted. Pupils PEARL at approx 4mm. VAN assessment negative. Patient denies any pain at this time. Vitals obtained as listed and are stable. No other significant assessment findings noted at this time. Rx: Vitals obtained as listed and are stable. No other treatments or interventions performed at this time. Tx : Patient verbalizes that she does not want to go to the hospital at this time. Patient does not usually sign tablet due to her medical history which includes dementia. Patient's family member who normally signs for EMS is not present. Patient's remaining family member thanks EMS for coming, but declines transport on behalf of patient. This family member states that she does not feel comfortable signing for patient, but signs as a witness to patient's statement of not wanting to go. M9-3 cleared on the patient refusal by family member, with witness signature obtained. Family member is advised to call 911 back immediately if patient changes her mind and requests transport, or if the condition persists/worsens in any way. Patient's family member thanked EMS for coming, and advised she would call back if needed. Ex: Patient unable to sign refusal document (see above). Witness signature obtained as listed. No other exceptions noted at this time.

44. Documentation Examples Good and Bad M9-2 dispatched for the medical emergency. Unit AOS to find a single male pt sitting on an exam table with no obvious signs of illness/injury. Pt contact was made and an initial assessment was performed by EMS. MD on scene reports pts visit to the office for a vitals check after experiencing a fall earlier this morning. MD reports hypotension and abnormal findings on an ECG that was taken prior to EMS arrival. No other assessments were performed by the MD and pt care was transferred to EMS. Pt reports the fall this morning being caused by a sudden feeling of lightheadedness, followed by "seeing spots" and weakness. Pt report hitting his head on the floor, receiving a small contusion to his nose and upper lip. Pt denies C/T/L/S spine pain and report no other signs of trauma. Neuro assessment performed on scene showed no signs of deficit. No other assessment findings to report.

45. Documentation Examples Good and Bad Pt agreed to transport and was able to stand and walk a total of 10 steps from the exam table to the waiting stretcher where pt was seated and secured using all safety restraints. Pt was moved from the scene to the unit via stretcher and loaded aboard without issue. Transport was initiated. Full assessment, RX and transport noted below: Assessment: Pt is AOx4 with GCS of 15. Pt is able to answer all questions appropriately and with normal affect. Pupils are 3mm and EARL. Airway is patent, resps are adequate and non labored with clear BS bilaterally upon auscultation. Symmetric chest rise and fall noted. Skin is cool and pink and dry with poor turgor. Strong, equal and irregular radial pulses noted bilaterally. No other signs of trauma found. No other assessment findings to report.

46. Documentation Examples Good and Bad RX: Pt was placed on the monitor with a 12 lead performed with findings noted in the chart. IV access obtained as noted in chart. IV fluids given as noted in chart. Medications withheld due to Asymptomatic Afib (Pt denies chest pain, AMS, hypotension, signs of shock, etc.). All vitals were continuously monitored with no other interventions performed. Transport: Pt was transported non emergent to VCU Tappahannock with a report given via phone with no orders received. pt was moved into the ER via stretcher and taken to room 8 where pt was able to stand and walk without assistance from the stretcher to the bed without issue. Full report given to nursing staff who assumed pt care without issue. M9-2 returned to service.

47. Documentation Examples Good and Bad D - for sick person. Complaints of fever/tachycardia/failure to thrive A - ATF 92 yom laying in bed supine/semi fowlers with first reponse personnel around. Patient would mumble when his name was spoke, but no other acknowledgement. C - Per nursing staff patient hasn't eaten in three days, and he was noted tonight to have a fever and be tachycardic . H - Nursing staff not very helpful with information, but stated that he hasn't eaten anything/much the last three days, he was noted to have a fever of 100 tonight with HR of 118. Patient being sent to hospital for evaluataion of possible sepsis. Patient noted to be somnolent/ responding with mumbles when his name is called, and seems to follow simple commands. Patient has history of foley cath in place with appx 300 cc of dark cloudy urine in bag. Last reported emptied at 1500 hrs.

48. Documentation Examples Good and Bad A - ATF 92 yom laying in bed. Patient AOX1, ABC's intact, GCS - appx 11. Patient appears to be somnolent. Nursing staff report that patient has a fever, hasn't eaten much in 3 days, and is tachycardic . Patient skin - normal, warm, and dry. Patient oral mucosa appears dry. patient pupils 3mm RTL, but sluggish. Patient has symmetrical facial features with minimal verbal cues, but appear to have no droop. Patient has no noted or reported pain or trauma to head or neck. patient has no signs of respiratory distress, no JVD. Lung sounds clear. Patient has no obvious bruising or crepitus to chest, no tenderness to palpation. Patient has normal abdomen, no swelling or bruising noted. Patient has foley cath inserted, no bruising or trauma noted to site. patient has appx 300 cc of dark, cloudy urine in bag, reported only output since 1500 hrs today. Patient has good PMS to all extremities with apparent purposeful movement. R - Assessment done, V/S obtained and noted. EKG shows sinus tachycardia without ectopy, 12 lead shows same, no acute ischemia noted. Later during transport an occasional but rare PVC was noted. IV established 18g to left FA with NS at WO rate for 300 cc, then slowed to KVO with total of appx 400 infused. EtCO2 noted to be 27-30. Unable to obtain an accurate sat, but patient placed on oxygen at 4 liters due to sats being 92 at facility. T - Patient transported to Mary Washington Hospital as preferred hospital. Patient moved to stretcher via full lift. Patient secured with all straps. HR decreasing and patient seeming to be slightly more active enroute . No other changes noted. Patient tolerated transport well, moved into hospital on stretcher and moved to bed by full lift. Patient care to staff in ER bed 23 with report to nurse Sarah A. E - Patient unable to sign due to ALOC.

49. Documentation Examples Good and Bad M9-3 dispatched to Colonial Beach, Va. 22443 for an 84 year old female patient who has fallen and has left hip pain. CBVFD and WDES ES-1 were dispatched and on scene providing care prior to our arrival. C: Patient's was utilizing her walker this morning, slipped and fell down. Left hip pain and left foot was rotated outward. H: UTI Currently on antibiotic, GERD, COPD, Dementia, NKDA, A: GCS 15, BP 130/55, RR 16 clear, SP02 92 on room air, pulse 90 regular, left foot was turned outward, 1st responders had wrapped pelvic are with a sheet for stabilization, 4 & 12 lead ECG display a sinus rhythm, Left hip pain was rated 8/10, the patient requested something for pain management when asked R: 30 mg Toradol IM, The patient stated that the Toradol had decreased the pain level but wasn't able to provide a number on the pain level scale T: The patient's family requested transport to MWH ER for evaluation. The transport was uneventful and patient care was transferred to MWH ER #8 without incident. EMS Supplies were replaced, REMS Medication Box exchange and M9-3 returned to service.

50. Documentation Examples Good and Bad Westmoreland County Medic 9-1 was dispatched to for a 63 year old male with difficulty breathing. Upon arrival, the crew of Medic 9-1 found the patient sitting on the living room couch. The patient was alert and oriented, displaying an open and patent airway, increased rate and work of breathing, and adequate circulation. Normal neuro exam. The patient's family were on scene, and explained that the patient had possibly been exposed to mold or other contaminants while on a job site - resulting in increasingly worsening dyspnea over one week. They provided a medical history of hypertension and stroke two years ago. No reported medication allergies (patient confirmed). They explained that patient had been seen at an urgent care and sent home with albuterol. The patient had completed two treatments prior to EMS arrival.

51. Documentation Examples Good and Bad An initial focused respiratory assessment revealed a tachypneic patient, with pulse oximetry of 98%. Lung sounds were clear and equal bilaterally with equal chest rise, no accessory muscle use. A 12 lead obtained on scene revealed a sinus rhythm with varying ST changes, not meeting STEMI criteria. Coach breathing was utilized to assist with the patient's distress. Initial oxygen administration withheld to avoid hyperoxia /toxicity. The patient was assisted to the stretcher at the residence, properly secured and moved to the medic unit. Once inside, Paramedic established a 20G saline lock in the left AC in one attempt. Site properly cleaned, secured, tourniquet removed, sharps in box. Due to the patient's distress, and unknown cause - emergent transport was initiated to MWH. ETCO2 was applied, revealing hypocapnia . It was additionally noted that the patient's oximetry was declining with distress. A non-rebreather was applied which was then escalated to continuous positive airway pressure. A peep of five was achieved and maintained throughout transport. Patient was significantly restless throughout transport, often removing diagnostic equipment due to movement. When patient would cooperate, oxygen saturation would improve to 98% as documented in vitals field.

52. Documentation Examples Good and Bad The patient tolerated CPAP well, stating through the mask that it was improving his distress. Frequent respiratory assessment was repeated, Paramedic noted the development of expiratory wheezing. A duo neb was administered which improved the patient's presentation. For the remainder of transport, the patient responded well and was able to answer questions with less difficulty and distress. Continuous patient monitoring performed including end tidal capnography / capnometry , and cardiac monitoring performed. Upon arrival, patient care transferred to nursing staff at MWH.

53. Documentation Examples Good and Bad Called for a male subject who is dizzy. Upon our arrival the pt. care giver meet us at the door. She stated he has been dizzy all day and she checked his blood pressure it was 80/50. That he was seen at VCU-Tappahannock Sunday for chest pain but she was unsure of his diagnoses. I took the pt. blood pressure it was 90/60. The pt. was able to walk to the cot outside the door. Once in the ambulance a 12 Lead ECG was done and the monitor interpreted it as sequential pacemaker, pt. does have a pace maker. An IV was started 18G lt. AC saline lock pt. blood pressure did rise during transport. The pt. had no complaints en route to VCU-Tappahannock Hall bed #1.

54. Documentation Examples Good and Bad Dispatched to Colonial Beach, Va 22443 for chest pain. 96 y/o white male with c/c: Difficulty Swallowing. Arrived on scene to patient standing in the living room alert and oriented x4. Pt had a normal work of breathing with equal fall and rise of the chest. Pt's airway was patent. Pt walked over to recliner for an assessment. Pt skin was warm and dry. Pt advised around 0300 hrs while laying in bed, he started to feel chest discomfort. Pt believes the cause of the discomfort is from possible food lodged in his esophagus. Pt pointed out the pain to be in his epigastric area. He advised pain is periodic and about 10 mins apart. Pt advised he has been having trouble with difficulty swallowing food/liquids for the past 10-12 years. Doctors advised the patient, he is unable to get his esophagus stretch due to his age and they are not comfortable sedating him. Pt advised he feels okay now, but still having epigastric pain. Pt attempted to drink tea w/ ginger and water to help dislodge the food and it helped with the pain. Last oral intake was pre-cut peaches with syrup.

55. Documentation Examples Good and Bad Baseline set of vitals obtained and documented. 12 lead EKG obtained - AFIB. Lung sounds - clear BIL. Patient had excellent PMS in all four extremities. Pt requested to be transported to the ER for further evaluation. Pt was assisted to stretcher via walking w/o difficulty. Pt was secured to stretcher and moved into the medic unit for further evaluation. Additional set of vitals obtained and documented. Pt was placed in position of comfort. Administered oxygen @ 2lpm via NC attached to end-tidal. Initiated pri 3 transport to MWH. En route to MWH: Continued to monitor the patient. Pt remained stable during transport. Pt had no further complaints. Pt rested comfortably on the stretcher. MWH notified via phone. Arrived to MWH, Pt care transferred over to ER staff in triage. Medic 9-1 restocked/ deconned @ MWH. Medic 9-1 returned to service. Additional hx : hiatal hernia

56. Documentation Examples Good and Bad Dispatched for a "Sick Person," arrived and found the patient sitting in his Living Room chair awaiting our arrival. CC: General Weakness HPI: Pt states he has been feeling fatigued/weak since tuesday , today he states he's so fatigued he can't stand up and bear his own weight. Pt also has a fever and cough, but denies any other COVID symptoms/exposures. Pt states he's had lower abdominal pain but no other issues.

57. Documentation Examples Good and Bad Assessment: Pt is A&Ox3, presenting with good perfusion, Skin Hot/Dry, -HEENT, Pupils PEARRL, -JVD, -Tracheal deviation, -Neck and back findings, -Chest Pain, -Difficulty breathing, lung sounds clear all quadrants, chest rise and fall symmetrical with adequate volume, abdomen soft but tender in both lower quadrants, pelvis is intact, -Upper extremity findings, -Lower extremity findings, Pt is non-ambulatory, PMSx4 = good and equal. RTT: No acute change Treatment and Transport: Vitals, Assessment, Transport via main stretcher in POC. Patient voiced no further concerns throughout transport and EMS noted no acute change. Patient care was transferred to VCU Tapp Hospital ER RN in the Hallway Bed 3, report given without incident.

58. Documentation Examples Good and Bad CDA falls. AOS to find a 72yom a/ox3 lying on the bed. Pt appeared normal in color, skin was normal to the touch. Pt c/o new onset of nausea and vomiting from previous fall that pt refused care for. pt appeared dizzier than before. Pupils ertl . Transferred pt to stretcher then in amb . Vitals taken. Placed pt on monitor showing paced rhythm. transported pt to VCU Tappahannock. Reassessed pt in route. Pt stated that nausea and dizziness had subsided. Med consult performed. Monitor pt and notify of any changes. Turned pt care ver to er nurse in rm 7.

59. Documentation Examples Good and Bad CDA sick person with severe flank pain, possible kidney stones. AOS to fid a 30yof a/ox3 sitting in chair on back deck. Pt appeared normal in color, skin was normal to the touch. Pt stated that she was diagnosed on 8/25 with multiple kidney stones. This episode of pain started at @ 09:00 this day. Pt had severe pain 10/10. Transferred pt to stretcher then in amb . Took vitals, bgl 95. Placed pt on monitor showing sinus rhythm. Established iv 20g lac s/l. Administered Ketorolac 30mg ivp with desired effect. Transported pt to MWMC. Reassessed pt in route, pain subsided to 3/10. No other changes in pt. Turned pt care over to er nurse. Med consult performed.

60. Documentation Examples Good and Bad Medic 9-2 Consisting of Primary patient caregiver, transport and as driver pilot, transport. Dispatched to residence with Response 3 and Law Enforcement an unknown problem. Patient called several times and hung up without saying anything. Crew staged and was advised by reponse 3 to enter in.

61. Documentation Examples Good and Bad Arrived on the scene to find a single story residence with no immediate outside dangers noted. No one answering the door. Neighbor came over to help assist in getting the door open. Law enforcement showed up and they assisted in getting the patient to open the door. Arrived to the patient to find a male sitting on the chair in the kitchen in no obvious distress and in the care of himself. Primary assessment completed: Provider impression is the patient appears to be awake and alert and displaying s pleasant demeanor with full control of all bodily functions. Primary assessment revealed the patient A/Ox3 with a GCS of 14, VS are stable. No severe distress is noted. VS assessed. No other immediate interventions required.

62. Documentation Examples Good and Bad Patient chief complaint: Patient states he was in bed and smelled someone in his house smoking weed, he got up and the man in the living room shot a gun at him, he picked up his shotgun and shot back at him. The male ran away. Patient states he has been coming in his house for the last several weeks. Patient states after this happened he became dizzy and tried to call 911. Patient HX, medications and allergies listed above. Patient chose to walk to the ambulance and sit on the stretcher. Patient secured with all belts and rails for the patient safety throughout transport. Treatments/Interventions were as follows: VS assessed successfully after each attempt

63. Documentation Examples Good and Bad 4 lead obtained successfully after 1 attempt and revealed a paced rhythm. BGL assessed successfully and revealed a BGL of 146 Patient assessment and examination Observation and monitoring Position of comfort for transport

64. Documentation Examples Good and Bad Provider secondary assessment reveals: NEURO/APPEARANCE: A/Ox3 with a GCS of 14, Normal speech noted, normal gait noted with no ataxia. equal grip strength, symmetrical facial features, Normal affect, Cincinnati stroke scale negative. DERMATOLOGICAL: Warm and dry, intact with no rashes noted, No jaundice of the skin is noted. No mottling, or cyanosis noted, Negative for petechia, purpura and birthmarks on visible skin. Negative for DCAP-BTLS. HEENT: Normal appearance, no blood or fluids are noted, PERRL at 4mm. No noted presence of raccoon eyes or battles signs. Patient denies recent blurred or doubled vision, No jaundice of the scleras is noted. Normal moist mucosa and breath odor noted. Patient denies recent headache, cough, nasal congestion, sore throat, fever, and rhinorrhea.

65. Documentation Examples Good and Bad NECK: Supple and symmetrical, mid-line is intact with no signs of JVD or TD. Atraumatic with adequate ROM, Patient denies pain or nuchal rigidity. CHEST: Equal chest rise and fall, patient denies chest pain, discomfort or tightness, Presence of pacemaker noted. CARDIOVASCULAR: Regular paced rhythm noted, S1 and S2 heart tones noted, patient denies palpitations. RESPIRATORY: BBS clear, equal and non labored in all fields, symmetrical chest wall expansion noted. Patient denies SOB, Patient does not have difficulty speaking between breaths. Breath sounds noted at the apexes and bases bilaterally.

66. Documentation Examples Good and Bad ABDOMEN: Soft and non tender, no abnormal distention noted, Patient denies pain in all four quadrants. GASTROINTESTINAL: Patient denies recent N/V/D. REPRODUCTION: No reproductive issues stated, full exam not indicated. BACK: Patient denies pain PELVIC: Stable and intact.

67. Documentation Examples Good and Bad ENDOCRINE: Patient states he is recently getting over a UTI, with no further issues noted. GENITALIA: NOT ASSESSED EXTREMITIES: +PMS in all present extremities, atraumatic with adequate ROM, gross and fine motor skills noted without deficit, no edema noted. Patient able to ambulate without issues. Patient denies pain. Patient was transported secured to the stretcher in the sitting erect position. While en route to the hospital patient was monitored and remained in stable condition without further complaints or concerns. Hospital contact made. Upon arrival at destination patient was taken to room 9 and placed in the bed via stand and pivot. Patient care report was given to staff and patient care turned over at that time without incident, change or delay.

68. Documentation Examples Good and Bad Called for a female with suicidal thoughts wanting to be transported to the hospital for evaluation, Law enforcement was on scene. Upon our arrival the deputy was standing by a camper in the back yard of a house. He stated the subject wanted to kill herself today and wanted to go to the hospital for help. The Pt. walked out of the camper crying and walked to the ambulance. Once in the ambulance her vital signs were taken. I asked the subject was she depressed she stated yes. I asked her did she want to kill herself she stated she tried to but her husband stopped her. the pt. was transported to VCU-Tappahannock bed # 4 with no change in condition.

69. Documentation Methods SOAP DACHARTE Chronological No one way is correct, as long as the necessary information is included

70. Documentation Methods SOAP S – Subjective – What you are told Description of patient – age and gender Chief Complaint What the patient tells you ie history, OPQRST, statements (include quotation marks if you are quoting) What other people on scene tells you Previous history, meds, allergies, physicians

71. Documentation Methods SOAP O – Objective – What you see/hear/feel Initial impression, including location and position Vital signs Physical exam finding – Primary and secondary asssessments Observation other information environmental, behavior, family Scene description/accident damage.

72. Documentation Methods SOAP A – Assessment – Your findings Diagnostic findings based off of physical exam Pertinent negatives Possible/rule out differential diagnoses

73. Documentation Methods SOAP P – Plan – What you did Should be in chronological order Treatments, and response to treatments (whether good or bad) Care administered prior to your arrival, how care was discontinued, transferred, and how patient was when care was turned over.

74. Narrative DACHARTE Method

75. Narrative DACHARTE Method D – Dispatch

76. Narrative DACHARTE Method Dispatch What type of call to what you are responding Mode of response Location Any other pertinent dispatch information

77. Narrative DACHARTE Method

78. Narrative DACHARTE Method Arrival What you saw when you arrived on scene How the patient initially presented

79. Narrative DACHARTE Method

80. Narrative DACHARTE Method Chief Complaint What is the patient complaining of, in their own words What family/caretaker/bystanders is stating the problem What you can see, using diagnostic tools, what is the problem

81. Narrative DACHARTE Method

82. Narrative DACHARTE Method History History of present illness Pertinent history relating to this illness Past history Additional statements the patient/family/spokesperson makes regarding the event or past pertinent events OPQRST can be included in this section if you feel it is appropriate

83. Narrative DACHARTE Method

84. Narrative DACHARTE Method Assessment Primary and secondary survey Noted injuries (DCAP-BTLS) OPQRST if not included in history LOC, pupils, GCS, Stroke scale Tenderness/pain to any part of body Extremities, trauma, PMS

85. Narrative DACHARTE Method

86. Narrative DACHARTE Method Treatment (RX) All treatments that were provided, as well as response to said treatment, good and bad Who did the treatment, splinting, or wound management Spinal immobilization, why or why not?, Field cleared, or refused?

87. Narrative DACHARTE Method

88. Narrative DACHARTE Method Transport/Hospital How patient was packaged, assessment , and treatments done during transport Where they were transported How they were transported Belts or other restraint devices used Where patient was transported Where patient was left at hospital Who assumed care

89. Narrative DACHARTE Method D – Dispatch A – Arrival C – Chief Complaint H – History A – Assessment R – Treatment (RX) T – Transport/Hospital E - Exceptions

90. Narrative DACHARTE Method Exception Any problems/circumstances that happened during the call Difficulty accessing patient Barriers to care (LE, language, refusing specific treatments, delay in treatments causing a delay) Deviations from protocol/guidelines

91. Documentation Methods Chronological Paragraph format Starting from dispatch until after turnover at hospital Can be easier to include some information Can sometimes help “paint a better picture” of on scene and presentation Imperative to keep in chronological order and accurately depict when things are done.

92. Refusal

93. Refusal CASE CLOSED C – Condition, Capacity, and Competence A – Assessment S - Statements E – Educate C - Consequences L – Limitation of EMS O – Offer Transport S – Signature E – Educational Material D – Dial 911

94. Refusal CASE CLOSED C- CONDITION, CAPACITY and COMPETENCE. Communication Understanding Appreciation Rationalization/Reasoning Determining a patient’s decision-making capacity requires professional judgment and a detective assessment. Should you conclude a patient lacks the capacity to make a healthcare decision, you must thoroughly document the facts that brought you to that conclusion.

95. Refusal CASE CLOSED A- ASSESSMENT As part of the refusal process, you should adequately explain, in non medical terms, your assessment findings to the patient. This allows the patient to process the information and your recommendations and to appreciate the outcome. During the process you must conduct excellent patient assessment and thoroughly document the following: - History of present illness or injury -Past medical history -Physical findings -Vital signs

96. Refusal CASE CLOSED S- STATEMENTS As you interact with the patient about their injury or illness, note any specific statements the patient makes. Document these statements carefully to demonstrate the understood their condition in their own words. Their documented statements should also reflect that they are refusing care and understand the risks involved. The refusal form they sign should acknowledge they are taking responsibility for the consequences for refusing care.

97. Refusal CASE CLOSED E- EDUCATE Educating patients about treatment options helps them make better medical choices. Provide all the information a reasonable person would find necessary and relevant to make a proper medical decision. This means enough to understand what would be in their best interest. Patients have a right to be informed of their options and alternatives.

98. Refusal CASE CLOSED C- CONSEQUENCES Discuss with the patient the potential risks and consequences of their refusing treatment and/or transport. They should be able to evaluate the consequences, weigh the risks and benefits, and reach a conclusion in keeping with their goals and best interests.

99. Refusal CASE CLOSED L- LIMITATIONS OF EMS EMS personnel must educate patients about their own limitations as well. For example, you can utilize a 12-lead ECG to rule in a myocardial infarction, but it can’t be used to rule one out. Ruling out an MI requires serial blood labs and ECGs performed under observation at a facility as a part of a process within the continuum of care.

100. Refusal CASE CLOSED O- OFFER TRANSPORT Always offer transport to the hospital, but how you offer that transport is an important part of the process. The patient’s perception often drives the decision. There is a big difference between “Will you go with me to the hospital?” And “You don’t want me to take you to the hospital, do you?” The first question lets the patient make the decision without undue negative influence. Document the number of times the patient refused your offer of transport.

101. Refusal CASE CLOSED S- SIGNATURE The patient refusal form is a legal document and must be signed by the patient. The refusal form or part of the report should also be signed by you and dated. A best practice is to have another person also sign the form, attesting they observed you explain the risks of refusing care and/or transportation. This individual should preferably be someone besides another member of the crew. In some cases, despite your best efforts, the patient or their representative may refuse to sign the refusal. In this case, document in the refusal form that the person refused to sign and what was stated during the process.

102. Refusal CASE CLOSED E- EDUCATION MATERIAL When you encounter a patient, conduct an assessment, and offer care, you have established a relationship of patient and provider. Prior to the termination of this relationship with a refusal, you have educated the patient about their condition and informed them of the risks of refusal. At this point you are essentially discharging the patient as if you had cared for them at a facility. At a hospital the patient would receive discharge instructions and information about their condition.

103. Refusal CASE CLOSED D - DIAL 9-1-1 At the conclusion of the process, inform the patient and or family to call 9-1-1 for EMS immediately if there is any change in the patient’s condition. Include this in your documentation as well. When patient’s refuse emergency medical treatment, communicate with them about their condition, recommend treatment and/or transport, risks, benefits and alternatives when appropriate. Documentation of the refusal of treatment and/or transport should include an assessment of the patient’s capacity, your delivery of information, and the patient’s autonomous choice.

104. Refusals Things not to say or Do Never tell a patient “you will be fine” Never tell a patient “you don’t need to go” Never tell a patient that the hospital is too busy Never tell a patient to go to urgent care or their PCP Never tell you patient to “wait and see what happens” Never lie to your patient Never refuse to transport Never suggest going POV

105. Refusals Things to say and do Always offer transport Always speak in layman’s terms Always do a thorough physical assessment Always do a competency assessment Always answer questions to the best of your ability Always ensure they understand limitation of EMS assessment, Risks and consequences, up to and including possible death Always document everything that was said and what was done

106. Required Signature Patient Signature Provider Signature Facility Signature Drug Waste Signature Drug Box Exchange Signature Refusal Signature

107. Signature Patient Signature Patient is first choice Legal guardian Relative Representative of agency providing transport

108. Signature

109. Signature

110. Refusal Signature If patient refuses treatment or transport, obtain patient signature along with witness, and second EMS provider witness. If patient refuses to sign Document refusal to sign Obtain witness signature LE or family member preferred Partner if absolutely necessary

111. Required Attachments Scan and attach Face Sheet (from VCU Tappahannock) EKG strip 12 Lead

112. https://www.hmpgloballearningnetwork.com/site/emsworld/article/10448486/processing-patient-refusal Billing timeframe