Documentation

[letmesleep]

We had a documentation class today, and it was your typical class about the subject as far as what we should and shouldn't be writing in our PCRs. During the class a few different types of documenting formats came up, such as:

S.O.A.P.

C.H.A.R.T.

C.A.T.

Do you use a format?

Are you required to use a format?

Is a format PCR a good idea (in your opinion)?

At my place of employment we have no specific format to document, and we see good and bad results from this. I personally write a narrative that is specific to each call with numerous consistencies from one but I am interested to know if there is a way that I could better my PCR skills.

[Kiwiology]

At my place of employment we have no specific format to document, and we see good and bad results from this. I personally write a narrative that is specific to each call with numerous consistencies from one but I am interested to know if there is a way that I could better my PCR skills.

History

What you found upon arrival

What you found upon assessment

Pertinent negatives

Treatment

After a lot of inaccuracy and problems with PRFs now there is an offical format (see above) and a list of abbreviations for use.

[letmesleep]

We had a documentation class today, and it was your typical class about the subject as far as what we should and shouldn't be writing in our PCRs. During the class a few different types of documenting formats came up, such as:

S.O.A.P.

C.H.A.R.T.

C.A.T.

Do you use a format?

Are you required to use a format?

Is a format PCR a good idea (in your opinion)?

At my place of employment we have no specific format to document, and we see good and bad results from this. I personally write a narrative that is specific to each call with numerous consistencies from one PCR to another, but I am interested to know if there is a way that I could better my PCR skills.

Sorry, I was interupted before I completed my thought. the bold highlight is an edit.

[JPINFV]

If I was to return to the field today, and after having SOAP beaten into me along with all of it's subsections, I'd use a modified SOAP note that I call "PSOAPD"

Prearrival: Dispatched code ____ for a complaint of _____. Insert any other important prearrival (wrong address, caught at a railroad crossing, etc).

Subjective:

History of Present Illness: (34 y/o male presents with a C/C of _____. OPQRST. History/allergies/medication that are directly related to the complaint)

Allergies (including reaction if possible)

Medications

Medical History

Surgical History

Family History (if appropriate)

Social History- (as appropriate) tobacco, alcohol, recreational drugs, sexual history.

Review of systems

General

HEENT (head, ears, eyes, nose, throat)

Neck

Resp

Cardiovascular

Abdomen

GU/GI

Musculskeletal

Skin

Neuro

Psych

Objective:

Physical exam following same organization as the review of system

Assessment:

DDx/protocol being followed

Plan:

treatments

Delta:

Changes in route, additional treatments due to changes.

Edited January 19, 2010 by JPINFV

[fireflymedic]

If I was to return to the field today, and after having SOAP beaten into me along with all of it's subsections, I'd use a modified SOAP note that I call "PSOAPD"

Prearrival: Dispatched code ____ for a complaint of _____. Insert any other important prearrival (wrong address, caught at a railroad crossing, etc).

Subjective:

History of Present Illness: (34 y/o male presents with a C/C of _____. OPQRST. History/allergies/medication that are directly related to the complaint)

Allergies (including reaction if possible)

Medications

Medical History

Surgical History

Family History (if appropriate)

Social History- (as appropriate) tobacco, alcohol, recreational drugs, sexual history.

Review of systems

General

HEENT (head, ears, eyes, nose, throat)

Neck

Resp

Cardiovascular

Abdomen

GU/GI

Musculskeletal

Skin

Neuro

Psych

Objective:

Physical exam following same organization as the review of system

Assessment:

DDx/protocol being followed

Plan:

treatments

Delta:

Changes in route, additional treatments due to changes.

Pretty darn close to what I utilize, with one exception - I put what dispatched to and what I found on arrival in case there is a conflict with dispatch and chief complaint so they can be reviewed on both sides. Also throw chief complaint in that section, and if accident - what surrounding features were found - ie intrusion, height of fall, what landed on, etc. Other than that, it's almost very close to what I follow.

[JPINFV]

The difference between dispatch CC (P section) and real CC (HPI in S section) is why I've got both listed, but in different areas. Accident conditions would fall into HPI.

[HERBIE1]

All good answers, letmesleep. I would also emphasize that you need to document any issues that cause you to alter your care or delays you may encounter- access to patient, extrication issues, patient's refusals to treatments, differences between patient statements and what you see, etc.

Everyone develops their own routine and how you document also depends on whether or not you have an electronic PCR. These electronic programs often have drop down menus that offer choices to document a delay to the scene- heavy traffic, road conditions, wrong address, etc. Be VERY careful when using these predetermined, computer generated options. As an example of potential pitfalls- the software we use has several different places and methods to determine the patient's GCS and level of consciousness and you need to ensure each section is in agreement, although they do not completely match up in content. It's simply a software glitch that everyone complains about and we are told because it is a proprietary product, they can no longer change the software without paying a huge fee.

An example of documentation issues-

I had to testify in a personal injury care case where the person had a head injury. As I said, the various level of consciousness sections of the report differed slightly, and there was a discrepancy between them. The lawyers were arguing whether the person was intoxicated or his agitation and actions were the result of the head injury and asked me about the variations. I explained to them about the computer issues, and at the time this software was also new. I also pointed out my VERY detailed comments that fully explained the patient's condition that left no doubt about his mental status. I said that I stand by my words, and any discrepancies with those mandatory computer generated options was the fault of the software designer, not me. The defense attorney and the judge understood and accepted my explanation.

Another-

A couple weeks ago we had a nasty roll over- highway speed. Guy was out of his car before we got there, sitting in a state trooper's cruiser. He got out as we arrived, and stepped into our rig. Our treatment was standard, turned out he had a tiny lac to his forehead, nothing more, but he went to a trauma center for evaluation. The pertinent point here was in the documentation.

Because this was a DUI case(the other driver was a fatality) police investigators caught up with us a few days later. We went over what happened, I reviewed my report, and noted a glaring error. I had correctly documented that the guy was ambulatory to our rig, but it also said that he was sitting on the squad bench as he rode to the ER, and walked into the ER when we arrived at the hospital. Obviously the guy was on a backboard and collar, on the cot, so there was no way he could have been seated in the rig, nor did he walk into the trauma center. I pointed this out to the investigators and complained bitterly about the computer program, and the officers said they have similar issues with their report writing software.

I ALWAYS review my runs for accuracy before closing them out and printing them, but I somehow missed the mode of transportation section. I inadvertently hit the wrong options and did not notice. It happens, but ultimately it is YOUR responsibility to ensure that report is a complete and accurate portrayal of the patient, his condition, and your treatment.

Learn your own method of report writing and use a cheat sheet if necessary until it becomes ingrained in your head.

I am known for my very detailed personal comments- even if they may repeat information elsewhere in the report because I know I can defend my own words. The story, in your own words, may also just save your butt and your reputation in court.

[JakeEMTP]

I pointed this out to the investigators and complained bitterly about the computer program, and the officers said they have similar issues with their report writing software.

Just curious Herbie, we have the Zoll "Rescue Net" programme for our ePCR's. While obviously not the best programme on the market, the number one thing I like about it is the ability to write my own narrative. I was just wondering if the programme you use has that feature or is it a computer generated narrative.

To the OP, I use the CHART method of writing a narrative. I just find it more comfortable for me. Which ever method you choose to use is fine as long as all pertinent information is included in it. Good advice from the other forum members!

[msenecal]

The important thing with documentation is developing a good system that you will use on the majority of your calls. I review many PCR over the week and all the providers that exceed at documentation all use the same style.

I feel it goes hand in hand with patient care most providers have a technique or system on managing and assessing a patient that don’t change it for every call.

[paraloco]

When we used paper run reports, I used the SOAP format. I hate the way the ePCr's print out. On the old reports, there was a box for the CC. I'd write the first thing the patient said after I asked what was wrong. "My babydaddymomma hit me with a baseball bat" or "I'm in danger" The way the report was laid out, it was easy to follow every step of the assessment and treatment. I have to use the comments section frequently now to correct erroneous charting from the drop down menus. There is no option for cataracts or missing eyes. There is no child or infant GCS scale. When I have an infant for a patient, I have to chart gcs 15, then in comments I write 'appropriate for age'. I do have to admit that the epcr alleviates the problem of poor penmanship. I'm told our collection rate has improved.