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mosby paramedic (4)

9/10/20121Chapter 4.Documentation2Lesson 4.1.Importance of .Documentation3Copyright © 2013 by Jones & Bartlett Learning, LLC, an Ascend Learning Company1.9/10/2012Learning Objectives.• Identify the purpose of the patient care .report• Describe the uses of the patient care report• Outline the components of an accurate, .thorough patient care report.4Reasons for Written .Documentation.• Provides tangible, legal incident record.• Used by physicians, nurses in patient care.– Read to understand initial condition, type of care given .in field• EMS agency, medical direction may.–.–.–.–Monitor care in field.Evaluate individual performance.Conduct review conferences.Seek other educational forums.5Reasons for Written .Documentation.• Written documentation provides for.– Tangible record of incident.– Legal record of incident.– Professionalism.– Medical audit.– Quality improvement.– Billing, administration.– Data collection.6Copyright © 2013 by Jones & Bartlett Learning, LLC, an Ascend Learning Company2.9/10/2012Reasons for .Personal Care Report (PCR).• Demonstrate continuity of patient care provided.• Have legal record of care provided.• Assist financial reimbursement, cost recovery for .care services, equipment, supplies.• Assist in quality improvement studies, EMS research7Reasons for .Personal Care Report (PCR).• Quality improvement.– Examples from PCR that may result in policy .changes, improve care.– Minimizing time spent on scene for critical .trauma patients.– Adding new medications to better manage some .medical emergencies.– Changing placement of emergency vehicles during .peak response times, certain demographic areas.8Reasons for .Personal Care Report (PCR).• Documents unique scene situations that may .have affected care.– Traffic caused long response time.– Entrapped patient required prolonged extrication• Aids in tracking care skills of paramedic.– IV lines, intubations, defibrillations.– May be required by EMS agency’s training division.– ALS skills documentation may be required by .some states for relicensure, recertification.9Copyright © 2013 by Jones & Bartlett Learning, LLC, an Ascend Learning Company3.9/10/2012General Considerations for PCR.• Carefully detailed, legible.• Legal document, part of patient’s medical .record.• Avoid slang terms, medical abbreviations that .are not universally accepted101112Copyright © 2013 by Jones & Bartlett Learning, LLC, an Ascend Learning Company4.9/10/2012General Considerations for PCR.• Required data.–.–.–.–.–.–.–.–.–Dates, response times.Difficulties en route.Communication difficulties.Scene observations.Reasons for extended on‐scene time.Previous care provided.Time of extrication.Time of patient transport.Reason for hospital selection.13Why should you note the previous .care given by bystanders in .your report?14General Considerations for PCR.• Provides legal, accurate recording for .incident times.–.–.–.–.–Call time.Dispatch time.Scene arrival time.Time at patient’s side.Time of vital sign .assessments– Time(s) of medication .administration, certain .procedures, defined by local .protocol .– Scene departure time.– Medical facility arrival time .when transporting patient.– Time back in service.15Copyright © 2013 by Jones & Bartlett Learning, LLC, an Ascend Learning Company5.