Guideline 1-700-33 - Patient Care Documentation

CMH EMS & MIH Protocols

Scope:

Guideline:

Purpose:

Procedure:

An ePCR must be completed for every EMS response (regardless of patient contact or transport status).

All PCRs shall be completed, faxed, and exported prior to end of shift unless approved by supervisor.

Appropriate documentation must be completed for each MIH encounter.

Suggested workflow:

• Update mobile: At the beginning of every shift, enter your credentials and click "update."
• Lock your chart: After writing your chart in Mobile, "Lock" it by clicking the checkmark in the top right.
• Sync records on the dashboard: The chart will no longer be accessible from Mobile. You can "sync" at any time to work on your chart on ESOsuite.net.
• Both "lock" and "sync" are required to finish your chart.

Incident tab:

• Response:
• Each responding ambulance needs it's own "incident number." If multiple patients per ambulance, add "A", "B", etc. to "run number."
• Incident Number configuration: 20X1234. "20" is the year. "X" is the station identifier:

• B = Bolivar

  H = Hermitage

  S = Stockton

  L = Eldorado

  C = Osceola

• Run Type:
• Use "911 Response" if an on-duty ambulance was needed for the response.
• Use "Medical Transport" or "Inter-Facility Transfer" if the scene location is at a hospital and the patient is under the care of a physician.
• Use "Standby" if a standby or public relation event. Enter the name and address in the patient data area. Narrative should explain why the ambulance was needed at the event.
• Response Mode:
• If dispatched priority 1 or 2, select "Emergent."
• If dispatched priority 3 or 4, select "Non-Emergent."
• Disposition:
• Disposition: Patient treated, transferred care to another EMS professional: Includes intercept and flight crews. Select the receiving hospital as the destination so the facility will be able to get your documentation.
• Transport Due To:
• Closest Facility: Should be used as the default.
• Diversion: If appropriate facility is on divert or diverted after giving radio report.
• Family Choice: Similar to patient's choice, but patient unable to make decision.
• Insurance: NOT USED.
• Law Enforcement: NOT USED.
• On-Line / On-Scene Medical Direction: Only used if transporting crew spoke directly with sending or receiving physician for orders.
• Other: NOT USED.
• Patient's Choice: Should only be used if patient refused closest facility AND facility recommended by protocol.
• Patient's Physician's Choice: Patient being transferred by physician order.
• Protocol: Should be used if closest facility was bypassed due to TCD.
• Regional Specialty Center: Used in conjunction with a protocol or physician order.
• Cancelled: Only if no patient contact was made.
• Destination: Chart number: From destination face sheet.
• General info: Epic usually uses "CSN", Cerner usually uses "FIN", and Meditech uses "Account#."
• CMH: Account number in top right of face sheet is "H" followed by 11 digits (i.e. H00001234567).
• Cox: Patient number (PT NO) in top right of face sheet is 12-digit number (i.e. 123456789012).
• Mercy: CSN number in top left of face sheet is 9-digit number (i.e. 123456789).
• St Luke's: CSN number in the top right of face sheet is 5-digit number (i.e. 12345). CSN can also be found on bottom left under the barcode.
• Times:
• Call Closed: This is the time back at the station. If another call, assignment, or errand is taken prior to returning to the station, the call closed time is the time that additional event is initiated. Examples: Dispatch time to a second call, arrival time on an MVA you drive up on, arrival time at a personal errand (if it will take more than a couple mintues) on your way back to the station.

Patient tab: History:

• Thoroughly complete this history section.
• Include only the previously diagnosed conditions, not the current condition (unless it has been previously diagnosed by a physician).
• Include smoking history with details of how much they currently smoke per day.

Vitals tab:

• A full set of vitals should be obtained on all patient contacts. Two full sets of vitals are preferred if patient contact is longer than 15 minutes. GCS and pain level are included in a full set of vitals.
• If 4-lead or 12-lead performed, at least one entry has ECG interpretation documented.

Flowchart tab:

• If a paramedic is present, add "ALS Assessment" and document findings on the Assessment tab.
• "BLS Assessment" is only required when COBRA form says BLS ambulance is required and if a paramedic is not present during the assessment. However, BLS Assessment can be added to any chart if one was completed.
• Include all interventions and assessments available (that were performed) in the selection lists.
• All assessment findings that require treatments available, must be listed with indications of whether they were successfully completed.

Assessment tab:

• All positive assessment findings must be listed.
• All treatments provided must coincide with an assessment finding indication as to why the treatment was needed.
• Double-check laterality. All assessment findings must indicate right- or left-sided must coincide with narrative and later documented findings of later assessments by other providers.

Narrative tab:

• Injuried: If fall, height of fall is number of feet between part of patient that struck an object and the object he/she struck. For example, a fall from standing striking their head might be five (5) feet.
• Narrative: Narrative should be a picture of how all the technical information from the rest of the chart played out on the call. Should be DRAATT format in chronological order with double space between each section for easier review:
• Dispatch: All details provided from initial dispatch. Examples include, but not limited to:
• Precise nature of call at time of dispatch.
• Was it scheduled?
• Response:How crew responded and any additional information provided while en route.
• Arrival: All details of the scene leading up to patient contact. Examples include, but not limited to:
• Scene size-up: What did you find?
• Observations that affect MOI and/or NOI.
• Location and position patient found.
• What is your first general impression of patient?
• Assessment: Initial patient presentation and assessment leading up to loading the patient for transport. Examples include, but not limited to:
• Document and describe any immediate life threats.
• Further expand on what was listed in the Assessment Tab with details of size, shape, specific location, color, odor, etc.
• What did the patient tell you?
• What is the patient’s baseline?
• Does the patient have decision-making ability?
• If the patient is pregnant, details of the pregnancy are required which include gestation or due date.
• If the patient has a prior amputation, details of the amputation are required which include which body part and location of amputation.
• If out-of-hospital transfer, the following details are required:
• Why does the transfer need to go by ambulance.
• Why does the transfer need to occur (what services are not available at the sending facility).
• What was the specific reason they are at the sending facility (i.e. diagnosis).
• Include short description of what was done for the patient at the sending facility.
• Discussion on ECG findings and interpretation.
• Discussion of lab values and interpretation. Coders are not able to interpret values. This includes examples such as (but not limited to):
• Low SpO2 must be interpreted and documented as "hypoxic."
• Low blood sugar must be interpreted and documented as "hypoglycemic."
• High temperature must be interpreted and documented as "hyperthermic."
• High capnometry with shark fin capnography must be interpreted and documented as "hypercarbic and obstructed."
• Treatment: All treatments performed and the patient's response. Include treatments indicated or considered but not performed and why.
• Transport: All details of patient reassessment and what happened during transport including patient hand-off to receiving provider. Examples include, but not limited to:
• Detailed description of how moved to stretcher.
• Clinical reason for destination or patient preference. If clinical, what was the clinical reason for that destination? "Higher level of care" is not a clinical reason for transport. Be more specific.
• Describe any changes from earlier assessments.
• Describe patient belongings and what did you do with them.

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• If PRC: Should be highly detailed covering all bases. Examples include, but not limited to:
• Does the patient have the ability to understand the ramifications of the decision to refuse care?
• If the patient does not have decision-making capacity, who is the responsible party the patient is left in care of?
• Discussed risks, etc. with family or other concerned party. Name of party.
• Narrative of the discussion with the patient and others (including noting what the patient repeated back to you).
• If the patient does not have decision-making capacity, list the physician’s name who was consulted when you contacted medical control.
• "Referral" to other care must be documented (i.e. POV to ER, walk-in clinic, follow-up with PCP, etc.).
• Document the Refusal Miranda was read out-loud to the patient and/or caretaker. Refusal Miranda can be found here: Protocol 2-682 - Patient Refusal.

Forms tab:

• Acute Coronary Syndrome Form should be completed on all patients with chest discomfort, altered mental status, syncope, nausea, dizziness, or weakness.
• Obstetrical Form should be completed on all pregnant patients.
• Spinal Immobilization Screening Tool Form should be completed on all trauma or fall patients.
• RACE Stroke Scale Form should be completed on all patients with altered mental status, syncope, nausea, dizziness, or weakness.
• Sepsis Screening Form should be completed on all patients with altered mental status, fever, suspected infection, or weakness.
• BEFAST Stroke Scale Form should be completed on all patients with altered mental status, syncope, nausea, dizziness, or weakness.

Billing tab:

• Details:
• Response urgency definitions:
• Immediate: You responded “as quickly as possible to take the steps necessary to respond to the call.” (i.e. you were dispatched priority 1 or 2).
• Non-Immediate: "Omega" EMD codes and scheduled transfers and standbys - all other calls should be "emergency." (i.e. you were dispatched priority 3 or 4).
• CMS service level definitions:
• ALS2: The patient required and receivied:
• At least three (3) separate administrations of one or more IV medications, OR
• At least one (1) of the following procedures:
• Defibrillation,
• Cardioversion,
• Pacing,
• Intubation,
• Surgical airway,
• Chest decompression, OR
• Intraosseous access.
• ALS1: The patient required and received:
• The complaint at the time of dispatch requires an ALS assessment and they received an ALS assessment. Refer to Protocol 2-924 - Universal Patient Care for the list of conditions requiring ALS. After the ALS assessment, the patient can be transported BLS (if appropriate) and still have a ALS1 CMS service level, OR
• At least one ALS intervention. ALS interventions are defined by those that require an AEMT or Paramedic license to perform (with the exception of starting an IV and giving isotonic fluids).
• BLS: Does not meet any of the conditions above. Only starting an IV and giving fluids does not make a patient ALS for billing purposes.
• Transport:
• Physician's Certification Statement (PCS) should be checked "Yes" or "No" on all transfers.
• Reason for Transport should be completed on all transfers. The reason must correspond with narrative and cannot only be for "higher level of care."
• Reason for Transport Comments should reference comments in the narrative tab.

Signatures tab:

• Billing Authorization: Start with section I and only move onto the next section if you are unable to complete the previous section.
• Section I: Patient signature is required for assessment and treatment.
• Section II: If patient is unable to sign, is there a responsible party that makes decisions for the patient (i.e. facility staff or parent). Responders and EMS should NOT be signing here.
• Section III: If patient is unable to sign AND no responsible party is present, obtain EMS and facility signatures.
• Standard Signatures: Complete ALL the appropriate sections.
• Provider Signatures: Obtain signatures from everyone assigned to the ambulance on that shift.
• Facility Signatures: Obtain signature from the provider taking over patient care (including flight crew). If signature cannot be obtained, type the agency name and provider name and sign "via xxxx" where "xxxx" is your signature.
• Refusal:
• This is required for all refusals including refusing all care, a specific treatment, or transport to recommended facility.
• Witness signature is required.
• PCS: This section is not required if a hard copy of the PCS is obtained from the facility.
• Custom Documents: Complete ALL the appropriate sections.
• Controlled Substances: Sign and obtain witness signatures if controlled substances are accessed.

Scanning hard-copy forms:

• All hard-copy forms shall be scanned and attached to the EHR. This includes PCS forms, face sheets, etc. The process to scan attach is:
1. Place forms on copier.
2. Button-presses may vary from copier to copier:
• The Bolivar variation is: Scan - Scan to Network Folder - Scan_Doc - Scan
• The Stockton variation is: Send - Address Book - Circle - "ESO_SCAN" - OK - OK - Start
3. Open ESO
4. Hamburger Menu
5. Attachments
6. Add Attachment
7. Browse
8. Files should be located here: F:/Depts/Pre-Hospita/Scan_Doc then the name of the location you scanned to.

Other reference sheets:

Refer to Guideline 1-450-33 - Documentation Reviewer Reference Sheet for info on how your charts will be reviewed prior to sending to Billing.

Refer to Guideline 1-800-33 - Clinical Reviewer Reference Sheet for info on how your charts will be reviewed for clinical competence.

CMH Pre-Hospital Services Mission: "Provide safe, exceptional, and compassionate care to our communities with an emphasis on highly trained and empowered staff."

CMH Mobile Integrated Healthcare Mission: "Provide exceptional, compassionate, and patient-centered care by a mobile collaborative team to improve patient experience, improve quality outcomes, and reduce healthcare costs."

Polk, Hickory, Cedar, & St Clair County EMS Protocols is licensed under a Creative Commons Attribution-ShareAlike 4.0 International License.