EMR ch8

Copyright ©2012 by Pearson Education, Inc.All rights reserved.

Emergency Care, Twelfth EditionDaniel J. Limmer • O’Keefe • Grant • Murray • Bergeron • Dickinson

Emergency Medical Responder: First on Scene, Ninth EditionLe Baudour • Bergeron • Wesley

CHAPTERCHAPTER

Principles of Effective Principles of Effective DocumentationDocumentation

88




1. Define the following terms:a. Continuity of careb. Electronic documentationc. Minimum data setd. Patient Care Report (PCR)

2. Explain the purpose of the patient care report.

3. Describe the elements of a typical patient care report.

(continued)




4.Describe the minimum data set required for the documentation of patient care.

5.Explain the procedure for correcting errors made during documentation.

6.List various tools used to document patient care in the field setting.

7.Demonstrate the ability to accurately document a simulated patient encounter.

(continued)




8.Properly correct an error made during documentation.

9.Value the importance of complete and accurate documentation.




TopicsTopics

• Patient Care Reports• Methods of Documentation




PATIENT CARE REPORTSPATIENT CARE REPORTS




Patient Care ReportsPatient Care Reports

• Documentation you provide is a permanent record of patient care you performed.

• Reports called run reports, patient care reports, prehospital care.

(continued)





• Some done by hand; some computerized (electronic).




Example of a patient care report form.




Electronic documentation of an emergency call is becoming more common.





• Reasons for accurate and complete documentation:– Continuity of care– Education– Administration– Quality assurance– Legal





• Elements of the PCR– Run data: information about call.– Patient data: patient information.

• Sections of the Report– Fill-in– Check boxes– Narrative





• Information in narrative should be objective rather than subjective.– Objective: straightforward facts. – Subjective: up for interpretation; may

include descriptions.





• Minimum Data Set– Time incident was reported to 911.– Time of dispatch.– Time of arrival at patient's location.– Time patient was transported from incident

location.– Time patient arrived at destination (e.g.,

hospital, aid station)

(continued)





• Minimum Data Set– Time patient care was transferred to more

advanced providers.– Patient's chief complaint.– Patient's vital signs.– Patient's demographics (age, gender, race,

weight).





• Correcting Errors– Cross out incorrect item with single line,

initial it, write correct number beside or above it.

– Never completely cover incorrect information; it may appear you are attempting to hide something.




An example of how to properly document an error in documentation.




Think About ItThink About It

• The quality of your documentation is reflective of the care you provide.

• How can data collection benefit EMS?• What elements would be essential to

document for a refusal of care?




METHODS OF DOCUMENTATIONMETHODS OF DOCUMENTATION




Methods of DocumentationMethods of Documentation

• Paper forms: – PCR forms filled out by hand.

• Computer-scan forms: – PCR forms completed by hand.– Fill-in-the-bubble format can be scanned

into computer for information management and statistics gathering.





• PDAs or handheld computers: – Specialized software allows emergency

care professionals to enter PCR information.

– Information then downloaded to computer devices at hospital, base, or main office.





• Laptop computers:– Software allows responders to complete

PCR on computer and print from docking station or send wirelessly to hospital or central database.




Two types of electronic tablets used for documenting patient care.





• Data-enabled cellular devices:– Advanced cellular data devices operate

PCR applications to complete and send documentation quickly and easily from cellular phones.




Think About ItThink About It

• How might electronic PCR be useful during an emergency with multiple patients?

• What legal circumstances might require review of a PCR?




SUMMARYSUMMARY




SummarySummary

• Patient care documentation is important:– Continuity of medical care to legal

proceedings.– Becomes permanent part of patient's

medical record.– Can be used by EMS organizations to

improve overall quality of emergency services.




SummarySummary

• PCRs Main Categories– Run data– Patient data

• Completed using combination of fill-ins, check boxes, and narrative areas.




SummarySummary

• Each PCR has a minimum data set as defined by U.S. Department of Transportation.

• Documentation errors should be corrected without trying to obscure erroneous information.

• Put single line through mistake, enter correct information above or beside it, initial change.




SummarySummary

• Patient care documentation completed:– Traditional paper-based forms– High-tech handheld computers– Data-enabled cellular devices

• Ensure accuracy and avoid subjectivity when documenting what happened on each response.




REVIEW QUESTIONSREVIEW QUESTIONS




1. What is the purpose of the PCR?2. What elements are typically included

in the PCR?3. What are the tools used to complete

documentation in the field?




Please visitPlease visitwww.bradybooks.com

and follow the Resource Central links and follow the Resource Central links to access content for this text.to access content for this text.

http://www.bradybooks.com/

EMR ch8

Healthcare

Transcript of EMR ch8