Medical-Legal and Documentation

Condell EMS System CE

September 2009 CE

Prepared by Debbie Semenek, RN, EMT-P

Objectives

Upon successful completion of this module, the EMS provider will be able to:

1. Identify the principles of EMS documentation 2. Discuss the confidential nature of the patient care report 3. Identify the potential consequences of illegible, incomplete, or inaccurate documentation

continued

4. Identify the special documentation considerations concerning patient refusals,

restraints, minors, and the behavioral emergencies5. Identify the purpose of the CMC EMS System

Request for Clarification, the EMS Incident Report, and the After Action Report

6. State the components of a valid State of Illinois advanced directive form

7. Complete all areas of the Patient Care Report at the completion of the class

The Patient Care Report

• Is the first medical record – creates a baseline

• Is a legal document

• An operational record

• Used for research

• Administrative tool

• Does your documentation reflect the care you gave to your patient?

Confidentiality

• The law prohibits the release of medical or other personal information about a patient unless:– The patient consents to the release– Other medical care providers have a need to

know– Is required by law (subpoena)– Need for third party billing

HIPAA

• Health Insurance Portability and Accountability Act• This act enhances the confidentiality of medical

records and mandates that EMS personnel be educated as to the requirements of the law.

• What do I need to know to do my job?• Do you know your departments procedure?

Report Writing

• Provides a step-by-step account of the care you provided

• Record of time sequence

• Reflects your professionalism

• Document exactly what you did, when you did it and the effects of your interventions

The Report

• A well written, thorough PCR suggests a thorough, efficient assessment and quality care.

• A sloppy, incomplete PCR suggests sloppy, inefficient care.

Special Documentation Considerations

• Patient Refusals are high risk and overused. Must include documentation of the patient’s state of mind. Must be an informed refusal.

• Explain why care is necessary. Inform the patient of the risks of refusal and document your attempts to do so.

• Any questionable, confusing, and/or complex refusal should be called in to Medical Control and documented while on scene.

Refusals

•  Have the patient sign the release statement which applies.There should be 2 witnesses to the release form. One should be the provider assigned to the ambulance and the other should be preferably a family member or bystander (e.g. police officer, etc.). Include witness addresses when possible.

Refusals cont’d

• Any patient who refuses to sign the refusal form should have this witnessed and signed by a family member, bystander, or police officer, if possible.

• If permission for release is gained over the phone (ie: from the parent), document “phone permission” and write in the parent’s name

• Perform complete assessments on your patient.

Refusals

• There must be detailed, written documentation that the patient appears mentally capable to refuse treatment and/or transportation. Complete documentation of the patients mental capacity includes a description of the patient’s orientation to time, place and person.

• Perform complete assessments on all patients including vital signs.

• When obtaining a release on a diabetic call, document the last blood sugar indicating a value over 60 and the patient’s current mental status

Restraints

• At times, the use of restraints may be necessary to protect the patient from harming themselves or others.

• Document the behavior that the patient was exhibiting that led you to the conclusion that restraints were necessary.

• Handcuffs are to be applied by Police Officers only. The police officer must accompany the victim/patient in the ambulance while being transported when wearing handcuffs.

Minors

• In Illinois, any person under the age of 18 is considered a minor, unless legally emancipated, e.g. pregnant, a married male/female. If the minor’s parent is less than 18 years of age, the parent can give consent for their child.

• Once a minor delivers, if they remain in the parental role, they remain emancipated regardless of living arrangements

• Minors cannot refuse transport, unless emancipated. • If a minor patient refuses to cooperate,remember that in

questions of competency to grant or refuse treatment, a person who legally is not competent to grant consent is also not legally competent to refuse consent.

Behavioral Emergencies

• Competent emotionally disturbed individuals have the same right to refuse treatment and transportation by EMS as other individuals.

• EMS should consider underlying problems and past history of the patient. Consider hypoxia, hypotension, trauma, etc.

Behavioral continued

• Documentation must include a description of the patient’s orientation to person, place and time.

• Put statements in quotes.• Document patient’s behavior.• If ETOH/Drugs are suspected, document what the

pt. tells you they ingested (in quotes). Describe any behavior the pt is exhibiting. Document the presence of liquor bottles, pills, etc.

Petition for Involuntary Admission

• Most of these forms will be completed by hospital staff– These forms cannot contain hearsay information– If you heard the patient make threats of harm,

then you would be involved in completing the form – especially if in the ED the patient denies making threats

• Transport to the closest ED unless patient makes a request or has a previous relationship

Involuntary Admissions

• Transport psychiatric patients to the closest ED– NOT okay to by-pass a hospital to take the

patient to a facility with a psych ward• The ward may not have available bed space• The patient may need to be cleared

medically prior to admission• Just because there is a psych ward in that

particular facility does not mean that patient would be admitted there

Involuntary Admission Forms

• To complete these forms:– Use “quotation marks”– Be objective– Can list others’ observations but state who gave

you the information and list that person under “witness”

• Note: without detailed information, the courts must often release the subject– Need facts to back up the allegations

Request for Clarification

• May be used by any System participant.

• The purpose of this form is to request an explanation (or clarification) of a specific situation such as: apparent deviation from the SOP’S, questionable orders, or any misunderstanding between hospital and provider personnel related to policy, procedure, equipment, a specific run.

Incident Reporting

• An incident is an occurrence, which is not consistent with the routine operation of prehospital care, or the routine prehospital care of a patient.

• The Incident Report Form is to be used for problems which are more serious in nature.

• Do not document on the PCR that the incident form was completed.

The PCR – Patient Care Report

• Is about the patient!• Complete all areas• Sections that do not apply should be marked not

applicable (N/A)• Sections that apply but were not assessed,such as

blood pressure, should be marked D/N/A (did not assess).

• Sections that cannot be completed because the information is unknown should be marked UNK

(unknown)

PCR

• All times should be recorded using the 24-hour clock.Midnight should be entered as 0000.

• Chief Complaint- is the complaint as stated by the patient, or in the case of an unconscious patient, the initial dispatch complaint.– Example “trouble breathing”

PCR

• Initial Impression-is your initial impression of the patient’s condition. It should match the treatment approach or protocol followed.

– Example: “Pulmonary edema”

• GCS-should be calculated on all patients and should reflect the level of responsiveness documented under “status” box.

Vital Signs

• For the stable patient, readings should be taken approximately every 15 minutes or more frequently.

• For the unstable patient, readings should be taken every 5 minutes or more frequently.

• Drugs-Record all medications given. Note the time, drug/solution, dose and route of administration.

• For IV fluids, include the size of the bag hung, IV catheter size and site.

PCR• Cardiac monitor-Rhythm interpretation is considered

part of vital signs. If you run a 12 lead EKG, check or “x” the box provided. Include a copy of the strip/ekg with the medical record and for the EMS staff. Record your interpretation.

• Crew signatures-the person completing the PCR should sign on the #1 line. Print names of other crew members in the remaining spaces.

• Crew member System ID numbers are added after each name.

• Paramedic students add “PS” after their name

Documentation Tips

• Use correct grammar and spelling• Correct errors by putting a single line thru

the error, write the correct information beside it and initial the change.

• Stay away from “appears” or “seems”• Document changes and responses to those

changes.• Document each time the patient is assessed.

Documentation

• Document pertinent negatives• Document why you deviated from normal

practice.• Does your treatment fit the observed

medical condition?• Continuation forms are available if you

need more room to write.• Always include assessment of o,p,q,r,s and t

PCR

• Always document delays in response. (Scene/transport activity that interfered with delivering care to the patient- train, weather, traffic).

• Document everything you do.• Your name is on the PCR, do you know what it says? Is

the information accurate?– Crew members should read over what is written

before the PCR is turned over to hospital staff• Only use approved abbreviations (CMC list). Limit use

of abbreviations.• If it’s not written down, you didn’t do it!

When should a PCR be written?

• Generate a patient care report each time you make contact with a patient. Having this document will never hurt you unless poorly completed.

• Abandonment is the termination of the EMT/Paramedic –patient relationship without providing for the appropriate continuation of care while it is still needed and desired by the patient.

Transfer of Care

• You cannot turn the care of a patient over to personnel who have less training than you without creating potential liability for an abandonment action.

• EMS Scene Transfer- If another unit/ department initiates patient care, obtain a report from them.

Suspected Abuse and Neglect

• EMS are mandated reporters for child/elder abuse /neglect (to DCFS and Abuse Hot Line). – Forms in the Paramedic rooms at the hospitals

• Document findings objectively. Use quotes when indicated.

• Relay all info to the receiving facility.• The receiving facility must also report the

incident to DCFS & Abuse Hot Line.

Medical Control

• Medical direction can only be provided by a licensed hospital. Acute care /Immediate care centers cannot give EMS orders. If you respond to a Acute Care Center, contact medical control in the usual manner.

• You can only transport patients with medication drips infusing that are in the SOP’s (ie: lidocaine, dopamine).

Region X Patient Management Plan

REMINDER:• Complete the Field Provider Log Form and

the After-Action Report– Can be completed by anyone on the call– Can be done individually or as a group

effort• Fax both forms to the EMS Office of the

Resource Hospital immediately following the incident

REGION X

MULTIPLE PATIENT MANAGEMENT PLAN

FIELD PROVIDER LOG FORM

Date: ________________________ Time: _______________________ Fire Department: _______________ Hospital you are contacting: ___________________________________ ED Phone #:___________________

CLASS 1: “Business as usual”

Field personnel call the closest appropriate hospital

“Hello. This is the __________________________ Fire Department. We are on the scene of a Class 1 multiple patient incident. The incident is a __________________________________________ (describe the event to the ECRN).

Our total number of patients is ________________. We have: (fill in the specific numbers of patients)

_____ Category I Trauma _____ Category I Medical _____ Category II Trauma _____ Category II Medical _____ Category III Trauma _____ Category III Medical How many patients can you take?” ____________ If patients will be transported to other hospitals report those destinations to the ECRN and record below. NO MORE THAN TWO PATIENTS MAY BE SENT TO HOSPITALS WITHOUT PRIOR APPROVAL FROM THE RECEIVING HOSPITAL.

Complete table with specific hospital name(s), #’s and patient acuities.

Ho

spital:

Ho

spital:

Ho

spital:

Ho

spital:

Cat I Trauma

Cat II Trauma

Cat III Trauma

Cat I Medical

Cat II Medical

Cat III Medical

TOTALS

NOTE: 1) Complete an After-Action Report (critique form) 2) Fax both this form and the After-Action Report to the EMS Office

of the Resource Hospital IMMEDIATELY following the incident.

CLASS 2 or CLASS 3 Field personnel call their Resource Hospital for Transportation Management

“Hello. This is the __________________________ Fire Department. We are on the scene of a Class __ multiple patient incident. The incident is a __________________________________________ (describe the event to the ECRN).

Our estimated number of patients is ___________. We estimate that we have the following types of patients: RED: _____ YELLOW: _____ GREEN: ______ DECEASED: _____

Our closest hospitals are:” (IMPORTANT: List in order of proximity to the incident)

1. ________________________________________ 2. ________________________________________ 3. ________________________________________ 4. ________________________________________ 5. ________________________________________

“MY CALL BACK TELEPHONE NUMBER IS”: _________________ *Use SMART® Command Board to record hospital availability and patient destinations. NOTE:

1) Complete an After-Action Report (critique form) 2) Fax both this form and the After-Action Report the EMS Office of

the Resource Hospital IMMEDIATELY following the incident.

Your Name: Contact Phone #:

Name:FD or Hosp:

REGION X MULTIPLE PATIENT MANAGEMENT PLAN

AFTER-ACTION REPORTDate of Incident: ________ Time of Incident: ________ Primary Fire/Rescue Agency: ___________________Description of Incident: ______________________________________________________________________Check One:

CLASS 1 : Total # patients: ____ (Specific # Trauma: Cat I___ Cat II___ Cat III___ Medical: Cat I___ Cat II ___ Cat III ___)

CLASS 2 / CLASS 3 : Total # patients: _____ (Specific #: Red _____ Yellow _____ Green _____ Deceased _____)

Please answer the following questions. Use the reverse side for additional comments (take note when faxing form).

Which hospital was first contacted by field personnel?______________________________________________

Mode of communication between field and hospital: Cell phone Telemetry MERCI Other:_______

Any difficulties with initial communication? No Yes:__________________________________________

Was it difficult to determine the ‘Class’ of the incident? No Yes:________________________________

Any difficulties with triage? No Yes:_______________________________________________________Receiving Hospitals / # pts to each hospital: ______________________________________________________

Any difficulties with patient disbursement? No Yes:___________________________________________

Any difficulties with ambulance to hospital communication (Class 1 only): No Yes:_________________

Was the two-sided Multiple Patient Management Plan REFERENCE CARD used? Yes No

If yes, was it helpful? Yes No Comments: _________________________________________

Was a Region X Multiple Patient Management Plan LOG FORM used? Yes No

If yes, was it helpful? Yes No Comments: _________________________________________Overall, how effective was Region X Multiple Patient Management Plan in successfully disbursing patients from the scene to area-wide hospitals?

Very Effective Effective Ineffective Very

Ineffective The success of the plan depends on your detailed comments. Please provide us with any additional information that may be helpful:_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Hospital Personnel – Submit this form and Emergency Department Log form to your hospital EMS Coordinator.Field Personnel – Fax this form and Field Provider Log Form to the Resource Hospital EMS Office.

Advanced Directives

• Components of a valid DNR order

– Must be a written document which has not been revoked

• Living wills may not be honored by EMS

Advanced Directives cont’d

– Advanced Directive contains the following:• Name of patient, name and signature of the

attending physician, effective date, the words “Do Not Resuscitate: and evidence of consent – either signature of the patient, or the patient’s legal guardian, or signature of power of attorney for health care agent or, signature of surrogate decision maker

How can we improve?

• Clearly document what you found when you arrived.

• Document a thorough patient assessment (include pertinent negatives)

• Make sure your treatment goes with your impression.

• Your treatment should demonstrate that you know and follow your SOP’s.

Improvement continued

• Document responses to treatment.

• Document patient condition on arrival at the receiving facility

• Take time to consider what you are documenting

• Get input from others on the call

• Be objective- avoid personal opinions

Case Reviews

• Now, lets review some PCR’S…. And remember that it’s easy to find faults in documentation. If you follow basic documentation principles the faults won’t be there and won’t be yours!

• To view the run reports, contact your department’s educational liaison.

PCR

• Remember- the PCR becomes a part of the permanent medical record- many people will see and review your documentation!

PCR Discussion #1

• Is legible- all areas are completed

• No abdominal assessment noted, initial impression- trauma to abdomen

• Ten weeks pregnant-ask about discharge, cramping (pertinent negatives)

• No witness on the refusal

PCR Discussion #2

• Is legible- but watch spelling – ie: seizures• What is routine medical care? IV, O2,

Monitor? or IV, O2, blood glucose?• “3 minutes after Morphine given”…

– Was morphine given? If so, why? Was there a med error? Any evidence of substance abuse?

• GCS info sloppy / hard to interpret• Drugs- add 0 before .9% = 0.9%

PCR Discussion #3

• Chief complaint-what did the pt tell you?or what were you called to?

• Initial impression-seizure?

• “Since Sunday”, when was Sunday?

• How was patient worse?

• IV-size of bag, site of catheter?

• Moved to MICU? RMC?

PCR Discussion #4

• History – does it say “several” neck ops?

• When was Friday?• Abdominal

assessment?• IV- size bag, site of

catheter, size of catheter

• Pain 8/10 & 8/10- what did you do to relieve pain?

• Heart rate-156- Are you thinking about why his rate is that elevated?

PCR Discussion #5

• Initial time is blank • How did pt “improve”?• Are heart rate and resp

rate normal for this 7 year old?

• Are side effects from the meds given?

• On scene time 20 minutes- is that too long?

• How was error corrected?

• Avoid “RMC”• Use pertinent

negatives here- no retractions, no nasal flaring, or use of abdominal muscles.

PCR Discussion #6

• DOA-• Watch spelling (“stomic”, “fowl”)• Correcting the spelling error – one line through

the word but needs to write “error” and place your initial

• “No obvious signs of fowl play”? Is that a police responsibility?

• Good documentation of the scene and how patient was found

PCR Discussion #7

• Initial impression (reflects the SOP to follow)- “Face pain” from what? Motor Vehicle Crash?

• What category trauma is the patient?• Description of injuries indicate potential

head/neck injury- patient not collared and boarded.

• Choking on blood- what could have been done for that?

• IV- what type of fluid?

PCR Discussion #8

• Did pt fall? Dispatched for a “fall” but this mechanism of injury was not clarified/addressed

• Watch “RMC” abbreviation• Was second IO successful? Did pt receive any IV

fluid volume?• Vitals taken every 5 minutes? Repeat pulse ox?• Any suspicion of substance abuse, alcohol?• Pain 8/10 & 8/10-where was the pain?

PCR Discussion #9

• What was the time of onset?• MVC- immobilization provided?

– Was this patient reliable?

• If pt is disoriented, do you believe her when she says she has no pain?

• No times on vitals or meds• Lung sounds? Why was lasix given?• Was 12 lead performed? Not checked on PCR• How much aspirin?• Long on scene time – any reason given?

PCR #9 continued

• A cardiac alert was called for this patient for suspicious ST elevation (negative on further evaluation)

• This patient did have a combination of issues: a low blood sugar and MVC.

• This is an example of tunnel vision- lost sight that this patient was also involved in a motor vehicle crash.

PCR Discussion #10

• Narrative indicates problems with staff at nursing home - This info should be placed on an incident report - not on the PCR.

• Description of seizure activity?• Lengthy on scene time?• What type of “stare”?• Suctioned patient? Was there an

obstruction?

Alteration of the original PCR

• What do you do if you realize that you omitted something from your report?– Complete a continuation sheet and write in

“addendum”– Do not back date the addendum; add date and

time the addendum was completed referring to the original report

– Forward the report to the respective facility the patient was transported to

Remember that the original report and copies must match!