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SOAP – Not just for your hindquarters anymore – Conclusion

The original plan was to type out one of these sections daily until I had finished it, BUT thanks to a standby yesterday that went a whole 4 hours longer than it was scheduled for I didn’t get a chance to post yesterday. SO lucky you. You get a double dose of documentation in a single setting… Don’t you feel special 😉

The A section is the place for your assessment of the patients condition, I know over the years we have all been told we don’t diagnose in EMS and that’s true, but it’s also a misconception. You HAVE to form some kind of opinion of what is wrong with the patient, otherwise how do you decide what to do for them? You have an opinion – write it down, the diagnosis box at the hospital will be filled in by the ED doc, and I don’t care how big a rock star you are. He isn’t going to just copy what you write down. Don’t be afraid to form an opinion of what is wrong with the patient or to express that opinion; even if you never say the words your treatment tells everyone what you suspect is wrong.

In the scenario patient we’ve been documenting his injuries are obvious and I would have absolutely no qualm with writing them down as you will see, but what about nana who presents with a medical condition you can’t be quite as sure of? You still will have formed an opinion of what is wrong with her, but you can’t be sure if it’s CVA, A TIA, or is secondary to a previous CVA and she’s just presenting with a case of generalized weakness. Two little letters R/O (rule out) come in extremely handy in these situations. You can list every suspected injury, illness or condition with confidence when preceded by the letters R/O; this is a suggestion to the ED that based on your assessment you believe they should look for ______________.

Generally speaking, that should be sufficient to satisfy even the most ardent defenders of the “we don’t diagnose” argument.

You wouldn’t dream of walking into the ED and in your hand off report telling the doc: Well Doctor Smith, the patient presented with an asymmetric smile, slurred speech and arm drift that occurred suddenly about 30 minutes ago, but I have no idea what’s wrong with her…. You would say she’s suffered a stroke. If you would say it don’t be afraid to write it as well, granted we can’t tell if the patient is having a TIA, or a CVA, but at this point neither can the doc… He needs to see if the symptoms resolve and examine the scans, but if this is a concern for you then list your assessment as: R/O CVA/TIA

Enough of my SOAPbox (pun intended) grandstanding, back to the narrative.

A:

Tension Pneumothorax

Intra-abdominal bleeding

Hypoglycemia

Fx Left Femur

Scalp Lac 

During our exam we confirmed each of these injuries; I have no problem writing them exactly as I did, if it makes you feel better put an R/O in front of them.

Finally the last section P – procedures – this is the section where you document EVERYTHING you did for the patient. This is one of the sections I see A LOT of people skimp on, I was guilty of it myself until I was set straight by my paramedic partner in an ED lounge one day. He had a valid point and I adopted the things he told me and my reports have never been better because of it.

We are required to obtain consent from our patients before we ever touch them right? DO you document it?

What about how the patient got into the ambulance, or if you fastened all the straps on the cot?

Then there is always how the patient got into the ED… I think you get the drift.

DOCUMENT DOCUMENT DOCUMENT – more than any other THIS is the section lawyers have a field day with, if it isn’t here you DID NOT do it period.

Disclaimer first – the treatments below are based on our local protocols, and any ALS interventions were suggested by one of our paramedics whom I greatly respect… I am a basic so if I botch the dosage or something it’s because I didn’t know any better – (that’s why I’m going to paramedic school next month after all)

P: Consent, assumed control of patient’s C-spine from bystander, primary survey, survey interrupted to perform needle decompression (10g, 2nd intercostal space, midclavicular line, with flutter valve), ventilatory assistance via BVM with reservoir and 15 LPM O2, initial survey resumed, Trauma activation called into St. Injury Trauma Hospital, interview, CMS check, C-collar sized and applied, Pt log rolled onto long spine board and secured with spider straps (back exam performed during log roll), head blocks applied and patients head and blocks secured to board with 2″ tape, CMS check, Patient loaded onto cot using long board by crew, foot of long board raised aprox 6 inches by placing med box under it (Trendelenburg), all 5 straps fastened and side rails raised, patient loaded into back of ambulance by crew, Patient transported emergent to St. Injury Trauma Center, vascular access (bilateral A/C, 14g angio, blood pump), BGL, fluid challenge 20ml/kg started (1600 ml total), vitals, 3 lead cardiac monitor, head to toe survey, 50ml (25 gm)D50 administered via established IV – Right arm, CMS check of Left leg, traction splint applied (to help relieve pain), CMS check of left leg, 12 lead cardiac monitor, vitals, repeat BGL, monitor decompression site for patency, call in consult to S.I.T.H Dr. Bones to administer 2 mcg/kg fentanyl, order received from Dr. Bones 1 mcg/kg fentanyl IV. 80 mg fentanyl IV via established IV in left arm, vitals, CMS check, patient unloaded from ambulance by crew on cot and wheeled into ED – red 1, patient transferred from cot to bed on long board by crew with assistance of SITH staff, hand off report given to trauma team RN, Patient and care transferred to SITH ED staff without incident.

John Q. Rockstar NREMT-P, Ambulance Company

————————————END OF NARRATIVE—————————————

While some of the treatments the patient got may be open for discussion, there is NO question about what was and what was not done for this patient.

So let’s take a look at the narrative from top to bottom start to finish.

 

NARRATIVE

Ambulance 123 and engine 456 dispatched emergent to go fast speedway at 123 any street for an auto-ped MVC

U/A found approx 20 YO M pt lying next to the race track in a semi prone position. Patient’s c-spine is being held by track employee and two other track employees are talking to the patient. Patient’s pants have a large tear in them in the left upper leg region and the left leg is bent at an awkward angle. Blood is visible in the patient’s hair and the patient appears very pale.

S: Pt is a 23 YO M. Patient states he “Can’t breathe” and his “chest and leg hurt”. Patient speaks in one to two word sentences and is confused and disoriented. Patient states that “a car drove right over me!” Patient states he isn’t sure how long ago this occurred.

HEENT: no complaints – pt states he “thinks he feels blood running down his face, but it could be sweat”

Chest: pt C/O pain to left chest – Pt denies having this pain before the collision, breathing/moving makes it hurt worse, pain is described as being sharp and squeezing at the same time, patient denies any radiation, pt rates the pain a 10

Back: no complaints

Abdomen: Pt C/O pain on palpation, patient denies any pain before accident, “you pushing on it” makes it worse, pain is described as dull all over his abdomen with no specific site, patient denies any radiation, patient rates the pain a 6

Pelvis: no complaints

Lower extremities: Pain to Left upper leg, patient denies having any pain before the accident, trying to move it makes it worse, pain is described as sharp and pulsating, patient denies any radiation, and rates the pain as a “12″

Upper extremities: no complaints

Allergy to PCN

Medications: insulin

PMHx: DM 2

Patient does not remember the last time he ate.

Patient also states he has a headache and some dizziness. Patient denies N/V/D as well as any LOC, but says he isn’t sure about that.

Bystanders give verbal report as follows: patient was walking from the pit area when he was struck by a vehicle traveling at a high rate of speed. Bystanders say that car did in fact drive over the patient saying he collapsed on impact and went under the car. Bystanders add that the patient was unconscious until just prior to our arrival. Bystanders also report that patient has not been moved and that track personnel were to him almost immediately keeping him still and “holding his head”.

O:

INITIAL EXAM

Airway: Open and patent

Breathing: Rapid w/ poor movement

Circulation: rapid radial pulse, minor bleeding from scalp lac, no major bleeding found

Skin: Pale, Cool, diaphoretic, cyanosis noted around lips

LOC: confused and abusive, won’t follow commands

Head: Blood in hair, no active bleeding, no other wounds noted, PERRL

Neck: No DCAP/BTLS noted, possible tracheal deviation to the right, positive JVD

Chest: Contusions noted to left chest, no paradoxical movement, crepitus and tenderness on palpation, breath sounds absent on left

Abdomen: slightly distended, tender to palpation

Pelvis: No DCAP/BTLS – intact and stable

Upper legs: Swelling, tenderness, deformity of left upper leg, normal CMS

Lower legs and arms: no injuries noted

Posterior: No DCAP/BTLS

Initial vitals: 90/50, pulse 150, respirations 36

GCS: 13 (eyes – 4, verbal -4, motor -5)

Sensory and motor function: normal

SECONDARY SURVEY: performed after initial interventions – en route to hospital

Airway: patent

Breathing: improved movement of air, less work to breathe, breath sounds now present on the left although diminished

Circulation: no major bleeding noted

Skin: pale, cool, diaphoretic, cyanosis around lips is improved

Vitals: 100/60, pulse 110, respirations 30

LOC: unchanged

GCS: unchanged

BGL: 40

Head: blood in hair from approx 4″ long scalp lac, no active bleeding, no battle sign or raccoon eyes, no drainage from ears or nose, face is atraumatic, PERRL

Neck: trachea appears more mid-line, JVD is no longer present – No DCAP/BTLS

Chest: unchanged

Abdomen: distension and tenderness are both increased from prior exam

Pelvis: unchanged

Upper extremities: NO DCAP/BTLS, Good CMS function

Lower extremities: Left leg in traction splint – CMS present, right leg no injuries noted

ONGOING EXAM: Performed after secondary interventions

BGL: 80

LOC: Patient is awake and alert, less combative and able to follow commands

GCS: 15

Breathing: movement of air continues to improve

Vitals: 110/70, pulse 110, respirations 30

Skin: unchanged

Neck: trachea remains midline and JVD remains absent

Chest: breath sounds still diminished on the left

Abdomen: distension/tenderness continues to worsen

Distal CMS on Left leg still intact and adequate

A:

Tension Pneumothorax

Intra-abdominal bleeding

Hypoglycemia

Fx Left Femur

Scalp Lac 

P: Consent, assumed control of patient’s C-spine from bystander, primary survey, survey interrupted to perform needle decompression (10g, 2nd intercostal space, midclavicular line, with flutter valve), ventilatory assistance via BVM with reservoir and 15 LPM O2, initial survey resumed, Trauma activation called into St. Injury Trauma Hospital, interview, CMS check, C-collar sized and applied, Pt log rolled onto long spine board and secured with spider straps (back exam performed during log roll), head blocks applied and patients head and blocks secured to board with 2″ tape, CMS check, Patient loaded onto cot using long board by crew, foot of long board raised aprox 6 inches by placing med box under it (Trendelenburg), all 5 straps fastened and side rails raised, patient loaded into back of ambulance by crew, Patient transported emergent to St. Injury Trauma Center, vascular access (bilateral A/C, 14g angio, blood pump), BGL, fluid challenge 20ml/kg started (1600 ml total), vitals, 3 lead cardiac monitor, head to toe survey, 50ml (25 gm)D50 administered via established IV – Right arm, CMS check of Left leg, traction splint applied (to help relieve pain), CMS check of left leg, 12 lead cardiac monitor, vitals, repeat BGL, monitor decompression site for patency, call in consult to S.I.T.H Dr. Bones to administer 2 mcg/kg fentanyl, order received from Dr. Bones 1 mcg/kg fentanyl IV. 80 mg fentanyl IV via established IV in left arm, vitals, CMS check, patient unloaded from ambulance by crew on cot and wheeled into ED – red 1, patient transferred from cot to bed on long board by crew with assistance of SITH staff, hand off report given to trauma team RN, Patient and care transferred to SITH ED staff without incident.

John Q. Rockstar NREMT-P, Ambulance Company

————————————END OF NARRATIVE—————————————

After reading through it top to bottom, do you have any question as to why this guy is in the ambulance, what is wrong with him, or how you intervened to try to help? Can you say the same thing about the last narrative you wrote?

Til next time…..

 

 

Posted by on August 1, 2011 in documetation, EMS, legal, Paramedic School

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SOAP – Not just for your hindquarters anymore Part 2

Yesterday we dove into the S – Subjective potion of the SOAP narrative, today we’ll move on to the O – Objective. This is the section of the narrative where you both document your examination of the patient AND what you found. For our young trauma patient we will have our rapid trauma survey, initial assessment from head to toe, secondary assessment as well as any changes we discover on subsequent exams. An important point to note here – in the first post of this series we talked about the fact that if it isn’t written down it wasn’t done, this is especially important in this section. Often many of us will fail to put the areas where we didn’t find anything pertinent into our objective section. We know that we checked the areas that aren’t listed there BUT someone picking up our PCR later that wasn’t on scene with us has no idea why it isn’t there. So list the results of your head to toe assessment – even if they offer no clue as to why your patient called 911.

I like to separate my initial findings from my secondary exam/response to treatment findings, but to the best of my knowledge there is no hard and fast rule about how this should be documented, form isn’t necessarily the most important aspect here – documenting what you did and what you found is.  A lot of providers out I have worked with will type their sections as one long paragraph – while this is acceptable (provided everything is in there) let’s pretend you are the ED doc who is going to look at the report – do you want to have to scan through the entire paragraph when all you need is three words buried in the middle, or would it be easier and more efficient for you to be able to look for findings related to your patients chest and pick them out instantly? No brainer right? We all bitch that our reports aren’t read and use that as an excuse to do a sloppy and incomplete job – it doesn’t have to be that way. If you want your reports read/used write them in a way that they are ACTUALLY readable/useable.

Just like yesterday, actual narrative is bold – comments are in normal font. At the end of today’s entry, I’ve included yesterday’s S section along with today’s O so we can begin to see the whole narrative in one place

NARRATIVE (Continued)

O: Findings on initial examination

Airway: Open and patent

Breathing: Rapid w/ poor movement

Circulation: rapid radial pulse, minor bleeding from scalp lac, no major bleeding found

Skin: Pale, Cool, diaphoretic, cyanosis noted around lips

LOC: confused and abusive, won’t follow commands

Head: Blood in hair, no active bleeding, no other wounds noted, PERRL

Neck: No DCAP/BTLS noted, possible tracheal deviation to the right, positive JVD

Chest: Contusions noted to left chest, no paradoxical movement, crepitus and tenderness on palpation, breath sounds absent on left

Abdomen: slightly distended, tender to palpation

Pelvis: No DCAP/BTLS – intact and stable

Upper legs: Swelling, tenderness, deformity of left upper leg, normal CMS

Lower legs and arms: no injuries noted

Posterior: No DCAP/BTLS

Initial vitals: 90/50, pulse 150, respirations 36

GCS: 13 (eyes – 4, verbal -4, motor -5)

Cardiac Monitor – 3 lead – Sinus Tach

Sensory and motor function: normal

At this point we have completed our “rapid trauma survey” and would make the decision that this is a “load and go” patient. There are some interventions that would have occurred during this portion of the survey: (needle decompression, ventilatory assistance, spinal motion restriction, etc) – however this section is about our findings not what we did – you will see the effects of those interventions on further exam but we won’t spell out in detail what we did until we get to the P section.

SECONDARY SURVEY: performed after initial interventions – en route to hospital

Airway: patent

Breathing: improved movement of air, less work to breathe, breath sounds now present on the left although diminished

Circulation: no major bleeding noted

Skin: pale, cool, diaphoretic, cyanosis around lips is improved

Vitals: 100/60, pulse 110, respirations 30

Cardiac Monitor – 12 lead – Sinus Tach

LOC: unchanged

GCS: unchanged

BGL: 40

Head: blood in hair from approx 4″ long scalp lac, no active bleeding, no battle sign or raccoon eyes, no drainage from ears or nose, face is atraumatic, PERRL

Neck: trachea appears more mid-line, JVD is no longer present – No DCAP/BTLS

Chest: unchanged

Abdomen: distension and tenderness are both increased from prior exam

Pelvis: unchanged

Upper extremities: NO DCAP/BTLS, Good CMS function

Lower extremities: Left leg in traction splint – CMS present, right leg no injuries noted

We have now completed our detailed head to toe survey, we have an idea that the interventions we initially provided for our patient are helping, and we identified another area that requires our attention, from this point forward we have identified all obvious injuries/concerns with this patient that we will be able to find in an EMS setting, subsequent exams/documentation need to focus on continued exam of problem areas and any improved/worsening conditions we find.

ONGOING EXAM: Performed after secondary interventions

BGL: 80

LOC: Patient is awake and alert, less combative and able to follow commands

GCS: 15

Breathing: movement of air continues to improve

Vitals: 110/70, pulse 110, respirations 30

Cardiac Monitor:  unchanged

Skin: unchanged

Neck: trachea remains midline and JVD remains absent

Chest: breath sounds still diminished on the left

Abdomen: distension/tenderness continues to worsen

Distal CMS on Left leg still intact and adequate

Unless you have an ungodly long transport time (in which case I hope you considered a chopper for this guy) if you get this much exam done you are doing fantastic – but this should give you an idea of how to document initial, secondary and focused findings on a patient who has several critical injuries. Now I’ve removed the comments and put the whole objective section after the Subjective section – if you put the two of them together you should be able to figure out what will appear in the A and P section as these are all based on the sections we have already completed, if at this point you can’t figure out what’s wrong with this patient either I didn’t document it properly or you need to review trauma 😉

Notice how easy it is to find what you are looking for when everything is separated into its own line and listed in the order of examination.

NARRATIVE

Ambulance 123 and engine 456 dispatched emergent to go fast speedway at 123 any street for an auto-ped MVC

U/A found approx 20 YO M pt lying next to the race track in a semi prone position. Patient’s c-spine is being held by track employee and two other track employees are talking to the patient. Patient’s pants have a large tear in them in the left upper leg region and the left leg is bent at an awkward angle. Blood is visible in the patient’s hair and the patient appears very pale.

S: Pt is a 23 YO M. Patient states he “Can’t breathe” and his “chest and leg hurt”. Patient speaks in one to two word sentences and is confused and disoriented. Patient states that “a car drove right over me!” Patient states he isn’t sure how long ago this occurred.

HEENT: no complaints – pt states he “thinks he feels blood running down his face, but it could be sweat”

Chest: pt C/O pain to left chest – Pt denies having this pain before the collision, breathing/moving makes it hurt worse, pain is described as being sharp and squeezing at the same time, patient denies any radiation, pt rates the pain a 10

Back: no complaints

Abdomen: Pt C/O pain on palpation, patient denies any pain before accident, “you pushing on it” makes it worse, pain is described as dull all over his abdomen with no specific site, patient denies any radiation, patient rates the pain a 6

Pelvis: no complaints

Lower extremities: Pain to Left upper leg, patient denies having any pain before the accident, trying to move it makes it worse, pain is described as sharp and pulsating, patient denies any radiation, and rates the pain as a “12″

Upper extremities: no complaints

Allergy to PCN

Medications: insulin

PMHx: DM 2

Patient does not remember the last time he ate.

Patient also states he has a headache and some dizziness. Patient denies N/V/D as well as any LOC, but says he isn’t sure about that.

Bystanders give verbal report as follows: patient was walking from the pit area when he was struck by a vehicle traveling at a high rate of speed. Bystanders say that car did in fact drive over the patient saying he collapsed on impact and went under the car. Bystanders add that the patient was unconscious until just prior to our arrival. Bystanders also report that patient has not been moved and that track personnel were to him almost immediately keeping him still and “holding his head”.

O:

INITIAL EXAM

Airway: Open and patent

Breathing: Rapid w/ poor movement

Circulation: rapid radial pulse, minor bleeding from scalp lac, no major bleeding found

Skin: Pale, Cool, diaphoretic, cyanosis noted around lips

LOC: confused and abusive, won’t follow commands

Head: Blood in hair, no active bleeding, no other wounds noted, PERRL

Neck: No DCAP/BTLS noted, possible tracheal deviation to the right, positive JVD

Chest: Contusions noted to left chest, no paradoxical movement, crepitus and tenderness on palpation, breath sounds absent on left

Abdomen: slightly distended, tender to palpation

Pelvis: No DCAP/BTLS – intact and stable

Upper legs: Swelling, tenderness, deformity of left upper leg, normal CMS

Lower legs and arms: no injuries noted

Posterior: No DCAP/BTLS

Initial vitals: 90/50, pulse 150, respirations 36

GCS: 13 (eyes – 4, verbal -4, motor -5)

Sensory and motor function: normal

SECONDARY SURVEY: performed after initial interventions – en route to hospital

Airway: patent

Breathing: improved movement of air, less work to breathe, breath sounds now present on the left although diminished

Circulation: no major bleeding noted

Skin: pale, cool, diaphoretic, cyanosis around lips is improved

Vitals: 100/60, pulse 110, respirations 30

LOC: unchanged

GCS: unchanged

BGL: 40

Head: blood in hair from approx 4″ long scalp lac, no active bleeding, no battle sign or raccoon eyes, no drainage from ears or nose, face is atraumatic, PERRL

Neck: trachea appears more mid-line, JVD is no longer present – No DCAP/BTLS

Chest: unchanged

Abdomen: distension and tenderness are both increased from prior exam

Pelvis: unchanged

Upper extremities: NO DCAP/BTLS, Good CMS function

Lower extremities: Left leg in traction splint – CMS present, right leg no injuries noted

ONGOING EXAM: Performed after secondary interventions

BGL: 80

LOC: Patient is awake and alert, less combative and able to follow commands

GCS: 15

Breathing: movement of air continues to improve

Vitals: 110/70, pulse 110, respirations 30

Skin: unchanged

Neck: trachea remains midline and JVD remains absent

Chest: breath sounds still diminished on the left

Abdomen: distension/tenderness continues to worsen

Distal CMS on Left leg still intact and adequate

 

Posted by on July 30, 2011 in documetation, EMS, legal, Paramedic School

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SOAP – Not just for your hindquarters anymore

One of the many things has changed over the years is the standardization of the narrative, early in my career a timeline story narrative was the norm, one gigantic block of information that you had to read from beginning to end. These days there are two preferred versions of the narrative – C.H.A.R.T. or S.O.A.P. I have heard conflicting versions of which of these is the “preferred” version to use, you know the one that will eventually be the be all and end all of narratives – at least until it changes (again).

My personal preference is SOAP, it works for me (after I was dragged kicking and screaming into the 21st century and forced to choose one or the other). So I am going to go into detail about SOAP over the next few days breaking it down into pieces that are easily manageable.

A frequent complaint I hear from people about SOAP is that they get confused about what information goes into each section, this is understandable until you get a feel for this type of narrative and how it works, but it’s actually quite simple. Everything your patient or a bystander says goes into S- put another way – everything you could learn about your patient if your eyes were closed belongs in the subjective section. Everything you see on exam belongs in the objective section – this is the place for reporting the findings of your actual examination of the patient. The A is assessment and is the place for you to record your “differential diagnosis” of the patient, while much has been said over the years about how important it is NOT to diagnose your patient in the EMS setting there is a way to convey what you think is wrong with your patient AND not write an actual diagnosis – we’ll get to that when we breakdown the A section in detail. Lastly, there is the P or procedures section… and A LOT more information goes here than you would think at first thought, I’ll go over some of the things you should have in there to help make that section of the narrative bulletproof.

Let’s get started shall we

This is totally fictional patient that I have taken from a testing scenario – so there is no concern about any potential HIPPA violations (honest chief)

I am not going to give you any of the call information as it came in, what the patient’s MOI is, or what injuries this scenario contains… because IF I document it properly – you should get all of those questions answered by the time I finish this narrative.

I always start my narrative with the dispatch information and what we found on arrival before beginning my SOAP narrative. Actual narrative will be bolded – comments will remain in normal font.

NARRATIVE

Ambulance 123 and engine 456 dispatched emergent to go fast speedway at 123 any street for an auto-ped MVC

U/A found approx 20 YO M pt lying next to the race track in a semi prone position. Patient’s c-spine is being held by track employee and two other track employees are talking to the patient. Patient’s pants have a large tear in them in the left upper leg region and the left leg is bent at an awkward angle. Blood is visible in the patient’s hair and the patient appears very pale.

At this point we have documented everything we know before getting out of the ambulance, we have defined the MOI, the approximate age of the patient, how we found them and given the general impression we formed – this guy is “sick”

Now that we have done all that it’s time to dive to into what the patient tells us when we approach.

S: Pt is a 23 YO M. Patient states he “Can’t breathe” and his “chest and leg hurt”. Patient speaks in one to two word sentences and is confused and disoriented. Patient states that “a car drove right over me!” Patient states he isn’t sure how long ago this occurred.

HEENT: no complaints – pt states he “thinks he feels blood running down his face, but it could be sweat”

Chest: pt C/O pain to left chest – Pt denies having this pain before the collision, breathing/moving makes it hurt worse, pain is described as being sharp and squeezing at the same time, patient denies any radiation, pt rates the pain a 10

Back: no complaints

Abdomen: Pt C/O pain on palpation, patient denies any pain before accident, “you pushing on it” makes it worse, pain is described as dull all over his abdomen with no specific site, patient denies any radiation, patient rates the pain a 6

Pelvis: no complaints

Lower extremities: Pain to Left upper leg, patient denies having any pain before the accident, trying to move it makes it worse, pain is described as sharp and pulsating, patient denies any radiation, and rates the pain as a “12”

Upper extremities: no complaints

Allergy to PCN

Medications: insulin

PMHx: DM 2

Patient does not remember the last time he ate.

Patient also states he has a headache and some dizziness. Patient denies N/V/D as well as any LOC, but says he isn’t sure about that.

Bystanders give verbal report as follows: patient was walking from the pit area when he was struck by a vehicle traveling at a high rate of speed. Bystanders say that car did in fact drive over the patient saying he collapsed on impact and went under the car. Bystanders add that the patient was unconscious until just prior to our arrival. Bystanders also report that patient has not been moved and that track personnel were to him almost immediately keeping him still and “holding his head”.

At this point we have conveyed all of the information we got from dispatch, conveyed how we found the patient, what prior aid if any was administered as well as all of the pertinent information we gathered verbally from our patient AND bystanderswe have completed the O, P, Q, R, S, T for each complaint as well as the SAMPLE history.

Now obviously we didn’t gather all of this information prior to leaving the scene, but since this isn’t a chronological report is does not matter when we got the info, just that we obtained it at some point.

Our objective assessment would come next, but that’s tomorrow’s post

Til Then…

 

Posted by on July 29, 2011 in documetation, EMS, legal, Paramedic School

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Documentation – Why bother?

During a conversation with one of the EMT students I had this week, the subject of documentation came up, it was bound to happen that they would find out about what many of us consider the absolute worst part of the job. It was only a matter of time before that “dirty little secret” came to light.

Speaking strictly for myself, documentation is the one skill I don’t ever want to “practice” – it seems so trivial to us in the grand scheme of things, that many of us are inclined to say things like “I didn’t take this job to be a billing specialist,” or some other equally inappropriate comment like “what difference will my documentation make to whether this patient lives or dies?” It’s not so much that we mind having to take the time to write stuff down, it’s just that it’s dull, boring and when not viewed in the light of how important it actually is,  it can be seen as a waste of time.

Documentation mostly gets a bad rap – we’ve all heard the line “if you didn’t write it down it didn’t happen”, many of us have likely heard something along the lines of  “oh sure make me write it down so it can be used against me later, “or perhaps you’ve gotten the call from the billing office that says “we can’t bill this trip because you didn’t document……”

It doesn’t have to be that way folks, let’s take a look at why documentation is so important and answer/address some of the common misconceptions we all too often have about it. Properly appreciating the value of good documentation can be had when we take the time to understand all the things those “seemingly meaningless” documents are actually used for.

From our standpoint as providers, the most important aspect of the patient care report (PCR) is that it is a clinical document that follows your patient through their hospital stay. It allows later providers to experience the event their patient is being treated for from the beginning to the present. Let’s put that in a context we can relate to:

  • How many times have you been able to get an accurate history of your patient at a nursing home? How frustrated do you get when you are unable to establish a “normal” baseline for your patient? Is that facial droop normal, how about the slurred speech and left-sided weakness? Ummm I don’t know they aren’t my patient, or I’m not the normal nurse over here – I’m just covering and I have never had this patient before ….

Speaking only for myself – I know what I think about the care that patient is getting or the level of professionalism of the caretaker I just spoke to. Do YOU want to be seen in that same light when some provider down the line tries to decipher your PCR and can’t get any information from it? I know I don’t want people to think about me or the care I provided to my patient that way.

Just as poor documentation that is missing important information says your care was sloppy and that you were not thorough in your treatment, professional documentation that is thorough implies that your care was as well. You can be the best provider in the world, but if your documentation looks as if it was done by a kindergartener, it will be ASSUMED that the care you provided was also performed at that level.

I know we all think our reports are totally ignored by ED staff but in actuality, they are carefully reviewed and incorporated into the patients chart.

Additionally, the documentation you write every day is what is reviewed when the effectiveness of our systems is critiqued. Studies on pre-hospital interventions are based largely on what we write in those reports, statistics, effectiveness of treatments even compliance with federal, state and local laws all are based on the documentation we provide.

The information you document in a PCR may not make a difference in whether or not that particular patient lives or dies – BUT it may make a difference in whether a patient you treat down the line does…  QA/QI processes are based almost solely on our documentation, and those sessions help determine how effective and appropriate our care was. QA/QI can be “painful” – espicially when it is your call under review. These sessions, in my experience, are generally not used as witch hunts where management goes looking for someone to blame for a negative outcome; instead, when used properly they are used to teach providers how to more effectively treat their patients in the future, maybe as a result of this process – local protocols are adjusted to allow us to better serve those who depend on us.

Of course you knew it was coming, any discussion of documentation would be incomplete without a discussion of the medical-legal aspects of what we write down, but we only ever see the downside of this. Instead of viewing your PCR’s as something to be used against you, I suggest you see them as your blue tights with the red S on the chest, your armor if you will. Thorough documentation is not something we should fear should a case go to court, instead knowing your treatment was solid, your decisions sound and your patient well cared for AND that you covered all the bases and documented all of that should alleviate that concern for you. Yes, we have all heard cases where pre hospital providers have been sued and some even where they lost, BUT those cases are due to POOR documentation.

We live an extremely litigious society, people will sue for anything they perceive as a payday for them, it’s a sad fact of the world we live in (and one of the reasons health care reforms will never achieve the desired results – sorry that’s another post). Instead of looking at your documentation as the weapon some ambulance chasing shark is going to use to surgically separate you and your retirement savings, view it is the shield that will stand up to the most rigorous of slimy lawyer assaults. You’ve heard it said if you didn’t write it down you didn’t do it… so counter that by simply writing it down. Civil suits usually start with a PCR being reviewed by some expert, their opinion of your REPORT (not your care) is often the deciding factor in whether or not a case progresses – a well-organized professional report will imply well-organized professional care and more often than not, will nip a suit against you in the bud.

Suppose it does progress further… suppose you are called to the stand to testify, how many calls do you run a day? Now multiply the number of calls/day by the number of shifts you work in say a year… can you still remember the details of all of those cases? Your PCR needs to have enough information to help you remember the call and the patient – go to whoever stores your PCR’s at the service where you work/volunteer and ask them to pull one of your PCR’s from a past call say a week, a month even a year ago – can you remember that call based on what you wrote in your report? If the answer is no you aren’t documenting accurately or completely enough to make yourself bulletproof… NOW is the time to fix that not when your retirement fund is on the line.

Billing – it is an unfortunate fact that ambulance services for the most part are businesses and as such they need to make money. Your PCR needs to document accurately what you did for the patient and why. Not only so that the company can make a buck, but more importantly so your patient isn’t unnecessarily billed for a higher level of care then they received or needed. If you run a paramedic/EMT car if the patient only needed BLS then they should only be billed for BLS, but you may need to justify that decision down the line, you can’t do that without proper documentation. It’s a pain in the ass and the single question that I absolutely HATE asking my patients “Mrs. Jones, can you tell me do you have insurance, and if so can you please provide me with the necessary information?” It makes me feel like crap and I hate asking… BUT recently I have begun to see this in another light as well. If I take the 2 minutes to get Mrs. Jones insurance information – how much hassle and headache am I saving HER down the line by having the bill sent directly to her insurance company? How much easier have I made dealing with the financial burden our services can cause by taking that simple step and documenting it. I look at it as an extension of patient care, and when I explain to my patients that I’m asking to save them the headache of sorting it out later, they are usually grateful that I asked, and that makes me feel a little better about asking.

The bottom line with billing… no it isn’t why any of us got into this line of work, BUT it is what KEEPS us in this line of work. Yes, there are services out there that do not bill (oh how I envy those of you that work for them) but for most of us, continued employment depends on continued operations and that my fellow provider is largely related to billing.

Luckily, documentation is a skill – it can be taught, practiced an improved and that will be what we’ll discuss the next few days.

Til next time…

 

Posted by on July 28, 2011 in documetation, EMS, legal

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