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Patient Care Documentation Pearls for Success

The following "Pearls" for completion of patient care documentation are presented by Lt. Melissa Doak of York County Department of Fire & Life Safety and are used within their performance improvement initiatives.  While we encourage all providers to follow their individual agency guidelines and procedures, this material has general applicability and, if adopted, would significantly improve our prehospital documentation in the region.

• Please try to get Social Security Number (SSN) of the patient or parent/guardian if under 18 years old
• Please be sure to indicate if a procedure was done or a medication given, did it work? Yes, no, sort of, or not all all, and explain in the narrative.
• Minimum of 2 sets of Vital Signs on transports if at all possible
• Signatures……all of them, patient, if patient is unable to sign (AMS, severe pain, dementia, unconscious, etc.) then Next of Kin or Receiving Nurse at ER indicating why the patient was not able to sign
• Sign your narrative (use you name, initials to identify the author of the narrative), it’s not always the person who logged into the computer, very important when students or those being precepting are writing reports
• Narratives are important for continuum of care, the medical record of the incident and for billing purposes
• Check boxes (although at times seem to be duplicating information found in the narrative) are REQUIRED for state data collection and for data that in turn, gets sent to the federal government, make sure all applicable check boxes are completed and if a check box or tab does not apply, mark it as not applicable or not required
• Don’t leave tabs or check boxes blank, blank boxes indicate incomplete information. If it does not apply, mark the – sign and indicate why, usually not applicable
• Addresses, please get a complete mailing address for the patient
• Controlled substances and narcotics-signatures for health practitioner who witnesses the waste at the ER
• Lights and siren use to the ER, please be sure to document why lights and siren were used en route to the ER in the narrative. Please see the PEMS Transportation & Destination Determination Policy found in your PEMS Protocol Manual, under Procedures, 1.e. to help you with this decision making.
• Refusals, remember to get a witness signature (when possible) including your other crew members as the witness
• If ALS is performed and it is a refusal, make sure Online Medical Control is consulted, per protocol. Document this in in the narrative. ALS = any ALS skills including application and interpretationof ECG tracings.
• Make sure the HIPPA Form is being given to every patient, when you ask them to sign the report, you are asking them to sign a document that says it has been provided
• Crew members-if EMS1 or another person gets on the medic unit for the transport, be sure they are included on the crew list and document any skills they performed
• Other units on scene, please be sure to mark “LAW” if law enforcement of any type was on scene, likewise, if another agency is also on scene, that information should also be included such as mutual aid engines or other mutual aid units
• Some ePCR’s do not detail everyone who responded or assisted in the call. For example, on a chest pain call, usually the engine crew and medic crew both respond when available, but many times, this information is left out on the ePCR. It should be noted everyone who did participate in the call for service, it should be clear in the EMS ePCR narrative
• Procedures-Use the check boxes when they apply even if the information is contained in your narrative
• Oxygen is a drug-and therefore should be documented when o2 is given in the medications given section
• If you are administering medications, you should know whether or not the patient has any allergies (unless of course they are unconscious, etc.) so please make sure this information is documented in the ePCR
• Weight based drugs given? If yes, there should be a weight of the patient included in the ePCR
• There is nothing wrong with scanning in the hospital face sheet if one is obtained. Be sure it is shredded after it is scanned in and remember to keep that document confidential following all HIPPA and Patient Privacy laws

Thanks to Lt. Doak for sharing this with us and allowing us to share it with YOU!