Documentation for ALL units

Documentation of calls that are cancelled enroute, standbys and no patient contact:

1-      Page 1 of emsCharts (completely)

2-      Page 8, activity log: documentation in a timeline format of the events of call to include what you were dispatched for, what you saw on scene (if arrived on scene), any tasks completed on scene, and who released your unit from the scene or cancelled your response.

Documentation of patient refusal calls:

1-      Page 1 of emsCharts (completely)

2-      Patient information page complete with appropriate information

3-      Page 2, page 3, page 4 and page 5 (complete and accurate)

4-      Page 8, activity log: documentation in a timeline format of the events of call leading up to refusal. This documentation should include any treatment provided to the patient to include vitals.

Medic Unit Documentation

emsCharts

If responding via a medic unit (M-3, M-5, EMS 300) a trip ticket needs to be generated. This will ensure accurate documentation and reporting for data collection at the local and state level.

Documentation of the response when patient contact is made by the Paramedic and the medic rides in on transporting unit:

1-      Page 1 of emsCharts (completely)

2-      Patient information left blank (no patient)

3-      Page 8, activity log: documentation in a timeline format of the events of call leading up to transfer of patient to transport unit. (“complete patient information and care is listed on 904, 403, etc… call report”); all patient treatment can be listed on transport unit ePCR.

Documentation of the response when patient contact is made by the Paramedic and the medic transfers care to the personnel on a transport unit and does NOT ride in:

1-      Page 1 of emsCharts (completely)

2-      Patient information page complete with appropriate information

3-      Page 2, page 3, page 4 and page 5 (complete and accurate)

4-      Page 8, activity log: documentation in a timeline format of the events of call leading up to and including transfer of patient to transporting unit personnel. This documentation should include any treatment provided to the patient to include vitals.

To: All Franklin County EMS System personnel

From: Brian Parnell, EMS Ops Manager

Jeff Bright, ES Training Officer

Subject: EMS charts documentation

Date: June 26, 2009

Listed below are some of the challenges we have found with emsCharts and some guidance to ensure that the patient care documentation is completed appropriately and accurately.

CAD #: There has been a problem with being able to utilize the same CAD # on multiple charts. The solution: use the identifier of the agency you are responding with at the end of the CAD # issued by dispatch. We understand there may be more than one unit from any agency to respond to an incident and at that time add a single numeric identifier at the end. (Examples: 200929941EMS, 200929941LRS, 200929941YRS, 200929941M5, 200929941BRS, 200929941EMS3)

Unit/Station #: Utilize the appropriate station location and unit number from the dropdown box

Referring: Ensure the correct information is added here. This is the address you are dispatched to. Please do not put in the patient’s name in the location box. Also choose the appropriate referring type from the selection box.

Receiving: Ensure the correct information is added here.

Mileage: Accurate mileage is needed. Some charts with transported patients do not have mileage documented.

Patient information: Name (correct spelling), Address (current), Date of Birth, Social Security number, and insurance information are needed. Please make all attempts to gather this information either from the patient, family or receiving facility. If you are utilizing the patient look-up feature, ensure the information is accurate and update as needed.

Page 2: Chief complaint: not necessarily the reason for dispatch however what the patient is stating is the reason for requesting EMS services; Scene description: description of what the scene looks like upon your arrival; this will be helpful if ever needing to recall information about the call; History of Present Illness: Description of how long the chief complaint has been affecting the patient; this is not the narrative section for the chart; information that you feel should be here to do a narrative should be placed in a timeline format in the activity log. Any of the other pick-list can be used as needed.

(EMS charts documentation continued)

Page 3: This page begins the patient assessment (Level of consciousness, ABC’s). This page is to be completed whether the patient is transported or refuses care. The responses here reflect how you found your patient; what you observed during the assessment not what you done for the patient. All patient treatment goes in the activity log.

Page 4: This is a continuation of the patient assessment. Again, the responses are what you observed, not treatment.

Page 5: This is the head to toe assessment of your patient. Appropriate responses are needed; if not listed in the dropdown boxes, free text in the appropriate comment section.

Page 6/7: Will not be utilized in FCEMS. The pages are for transport agencies that complete inter-facility transports as their mission.

Page 8: This is the page where you need to document the call utilizing a timeline method. All treatment given to patients is to be documented here using the boxes as appropriate. Ensure that you are choosing the appropriate protocol from the dropdown box. Same goes for the actions that may be performed during the call. Document as much as possible and what is appropriate. Please make sure you are documenting the facility, room #, and person you are releasing your patient to. If it is a refusal, then the pertinent information for release should be listed.

Page 9: Scanning all documents that are appropriate for the call. All charts will have the minimum of the signature page attached. If you place your patient on the cardiac monitor either for monitoring purposes or for cardiac related problems, a copy of the EKG needs to be attached to the chart.

All charts are to be completed and locked prior to the end of your shift or leaving your duty-station.

A QA program has been initiated to review patient care reports on a daily basis. This program will be reviewing charts to ensure appropriate documentation is completed along with deficiencies in patient care. Feedback from this will assist with improvement of all aspects of our patient care.

Any questions, contact Brian Parnell or Jeff Bright at 919-496-5005.

To: All Franklin County EMS System personnel

From: Brian Parnell, EMS Ops Manager

Jeff Bright, ES Training Officer

Subject: EMS charts documentation

Date: July 7, 2009

Listed below are some of the challenges we have found with emsCharts and some guidance to ensure that the patient care documentation is completed appropriately and accurately.

CAD #: Please begin utilizing EMS and unit # at the end of the CAD # for paid staff and the actual unit # for volunteers. Examples: 200931333EMS1, 200931333904, 200931333M3, etc.

Unit/Station #: Utilize the appropriate station location and unit number from the dropdown box. Still finding some charts with inappropriate responses.

Referring: much better however we are still finding “unknown” and “Franklin County EMS” in this box; the majority of our dispatches are to an address with very few exceptions and none are from Franklin County EMS. If requested by a Franklin County EMS unit, put the address you are responding to in the appropriate box and place “Franklin County EMS” in the requester/requested by box.

Receiving: Much better; continue to complete this.

Mileage: Mileage has gotten better.

Patient information: Much improvement; Name (correct spelling), Address (current), Date of Birth, Social Security number, and insurance information are needed. Please make all attempts to gather this information either from the patient, family or receiving facility. If you are utilizing the patient look-up feature, ensure the information is accurate and update as needed; if unable to obtain this information, please document in activity log the information that is not received and the reason for not receiving it.

Page 2: Chief complaint: not necessarily the reason for dispatch however what the patient is stating is the reason for requesting EMS services; Scene description: description of what the scene looks like upon your arrival; this will be helpful if ever needing to recall information about the call; History of Present Illness: Description of how long the chief complaint has been affecting the patient; this is not the narrative section for the chart; information that you feel should be here to do a narrative should be placed in a timeline format in the activity log. Any of the other pick-list can be used as needed.

(EMS charts documentation continued)

Page 3: This page begins the patient assessment (Level of consciousness, ABC’s). This page is to be completed whether the patient is transported or refuses care. The responses here reflect how you found your patient; what you observed during the assessment not what you done for the patient. All patient treatment goes in the activity log.

Page 4: This is a continuation of the patient assessment. Again, the responses are what you observed, not treatment.

Page 5: Normal has been removed from the dropdown boxes. Please utilize other descriptive terms in the assessment. If choice is not available in the dropdown box, please text the information in.

Page 6/7: Will not be utilized in FCEMS. The pages are for transport agencies that complete inter-facility transports as their mission.

Page 8: This is the page where you need to document the call utilizing a timeline method. All treatment given to patients is to be documented here using the boxes as appropriate. Ensure that you are choosing the appropriate protocol from the dropdown box. Same goes for the actions that may be performed during the call. Document as much as possible and what is appropriate. Please make sure you are documenting the facility, room #, and person you are releasing your patient to. If it is a refusal, then the pertinent information for release should be listed. This is your narrative section for the call

Page 9: Scanning all documents that are appropriate for the call. The notes page (the page that should be copied and left at the receiving facility) does not need to be scanned. All charts will have the minimum of the signature page attached. If you place your patient on the cardiac monitor either for monitoring purposes or for cardiac related problems, a copy of the EKG needs to be attached to the chart.

All charts are to be completed and locked prior to the end of your shift or leaving your duty-station.

Other notes: Use proper English when documenting: capitalize when appropriate (i.e. John Doe not john doe or JOHN DOE); do not use all capital letters or all lower case letters.