- Email: [email protected]
Principles of EMS documentation for mobile intensive care nurses
Pill and McCloskey/JOURNAL OF EMERGENCY NURSING
p o t e n s i o n , c o n g e s t i v e h e a r t failure, b r o n c h o s p a s m , a n d v e n t r i c u l a r d y s r h y t h m i a s . 1~ If t h e s e occur, sotalol t h e r a p y s h o u l d b e d i s c o n t i n u e d i m m e d i a t e l y a n d t h e i n t e r v e n t i o n s d e s c r i b e d in T a b l e 1 are s u g g e s t e d . 10
Summary Sotalol r e p r e s e n t s a n e w a n d b e n e f i c i a l t h e r a p e u t i c a l t e r n a t i v e for t h e t r e a t m e n t of l i f e - t h r e a t e n i n g ventricular dysrhythmias. With the rapid emerg e n c e of t h e s e n e w p h a r m a c e u t i c a l a g e n t s , it is imp o r t a n t t h a t e m e r g e n c y n u r s e s b e c o m e familiar w i t h b o t h t h e b e n e f i c i a l a n d a d v e r s e effects of t h e s e drugs.
References 1. Hohnloser SH, Woosley RL. Sotalol. N Engl J Med 1994;331:31-8. 2. Suttorp MJ, Kingma JH, Peels HOJ, et al. Effectiveness of sotalol in preventing supraventricular tachyarrhythmias shortly after coronary-artery bypass grafting. Am J Cardiol 1991;68:1163-9. 3. Kaumann A J, Aramendia P. Prevention of ventricular fibrillation induced by coronary ligation. J Pharmacol Exp Ther 1968;164:326-32.
Sometimes t h e p r o c e s s of r e v i e w i n g EMS r u n s h e e t s b r i n g s a c h u c k l e to a n o t h e r w i s e h e c t i c day. R e c e n t l y I s a w a n e n t r y t h a t r e a d like this:
CC: "Paper girl passing b y house. Reported unconscious individual in auto with engine running." Comments; "On arrival, found two n a k e d adults in auto e n g a g e d in sexual activities. Neither appeared to b e in any distress and w e returned to quarters." Not your o r d i n a r y c a l l . . , b u t t h e p o i n t at w h i c h w e b e c o m e laissez-faire a b o u t r o u t i n e c a s e s is t h e m o m e n t w h e n our e d g e is lost a n d w e are in d a n g e r
4. Carmeliet E. Electrophysiologic and voltage clamp analysis of the effects of sotalol on isolated cardiac muscle and Purkinje fibers. J Pharmacol Exp Ther 1985; 232:817-25. 5. Touboul P, Atallah G, Krikorian G, et al. Clinical electrophysiology of intravenous sotalol, a beta-blocking drug with class III antiarrhythmic properties. Am Heart J 1984;107:888-95. 6. Antonaccio M J, Gomoll A. Pharmacology, pharmacodynamics and pharmacokinetics of sotalol. Am J Cardiol 1990;65(Suppl): 12A-21A. 7. Schnelle K, Klein G, Schinz A. Studies on the pharmacokinetics and pharmacodynamics of the beta-adrenergic blocking sotalol in normal man. J Clin Pharmacol 1979; 19:516-22. 8. Sundquist H. Basic review and comparison of betablocker pharmacokinetics. Curt Ther Res 1980;28(Suppl):385-445. 9. Berglund G, Descamps R, Thomis JA. Pharmacokinetics of sotalol after chronic administration to patients with renal insufficiency. Eur J Clin Pharmacot 1980; 18:321-6. 10. Product information. Betapace (sotalol hydrochloride). Berlex Laboratories: Wayne, New Jersey, 1993. 11. American Hospital Formulary Service Drug Information. Bethesda, Maryland: American Society of Hospital Pharmacists, 1994:1062-66.
of m a k i n g m i s t a k e s . R e c e n t c o n t i n u o u s q u a l i t y imp r o v e m e n t m o n i t o r s in our EMS s y s t e m reveal t h a t q u a l i t y a n d a p p r o p r i a t e n e s s of care are not q u e s t i o n e d as often as t h e t h o r o u g h n e s s a n d accuracy of the docu m e n t a t i o n of t h a t care. Some m o b i l e i n t e n s i v e care n u r s e s (MICNs) m i g h t n o t realize t h a t they m a y b e leFor reprints, write Connie Mattera, RN, MS, CEN, EMT-P, c/o Northwest Community Hospital, 800 W. Central, Arlington Heights, IL 60065. J EMERGNURS1995;21:231-7 Copyright 9 1995 by the Emergency Nurses Association. 0099-1767/95 $3.00 4- 0
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JOURNALOF EMERGENCYNURSING/Mattera gally vulnerable if their documentation on telemetry radio (communications) logs is substandard. T h e log is only a " s c r a t c h p a d , " not p a r t of a formal record, a n d only s e e n b y MICNs, right? Wrongt In l e g a l terms, after a jury h a s d e t e r m i n e d w h a t t h e s t a n d a r d of care is, it m u s t r e v i e w t h e facts s u b m i t t e d as e v i d e n c e a n d d e c i d e w h e t h e r the MICN m e t t h a t s t a n d a r d . To m a k e t h a t decision, e a c h i n c i d e n t m u s t be reconstructed. P r e d i c t a b l y , l a w y e r s s u b m i t charts, run sheets, or t e l e m e t r y logs into t h e record. C o m p e t e n t l a w y e r s will scrutinize all s a l i e n t reports before i n i t i a t i n g suit. As we h a v e learned, sins of omission are as b a d as t h o s e of commission; t h a t is, t h e failure to i n c l u d e r e l e v a n t i n f o r m a t i o n in the m e d i c a l record can be as d a m n i n g as t h e information i n c l u d e d . The infere n c e s d r a w n b y a jury from t h e information pres e n t e d w e i g h s h e a v i l y on t h e c a s e ' s outcome. The G o l d e n Rule of D o c u m e n t a t i o n can b e s u c c i n c t l y s t a t e d as, " W o u l d the d o c u m e n t c r e a t e d at the t i m e of t h e call a i d in r e c r e a t i n g the run in t h e future?" Reports are often u s e d to jog or r e p l a c e m e m o r y of an incident. Jurors n a t u r a l l y v i e w w i t n e s s e s ' m e m ories as less t h a n r e l i a b l e b e c a u s e c a s e s are not tried for m o n t h s to y e a r s after t h e incident. If you are n a m e d in a suit, it is a s s u m e d t h a t you will h a v e s e l f - s e r v i n g r e c o l l e c t i o n s of facts. Therefore w r i t t e n d o c u m e n t a t i o n is the m o s t r e l i a b l e e v i d e n c e of w h a t d i d (or d i d not) h a p p e n . F i g u r e 1 p r o v i d e s several d o c u m e n t a t i o n models.
Admissible documents authenticating out-of-hospital medical control 9 Personal notes. S c r i b b l e s on n o t e p a d s are c o m m o n d u r i n g an u n e x p e c t e d call. If t h e s e are saved, t h e y m a y be e n t e r e d into the record.
9 Preprinted standard forms (communications log). There is no single, perfect m e d i c a l record form. The c o n t e n t s a n d c o n s t r u c t i o n often d e p e n d on local preference, a l t h o u g h s t a n d a r d d a t a sets for hospitals have been established through national g u i d e l i n e s (Joint C o m m i s s i o n on A c c r e d i t a t i o n of H e a l t h c a r e Organizations), a n d s t a n d a r d d a t a sets for out-of-hospital p r o v i d e r s h a v e b e e n e s t a b l i s h e d at t h e federal level (Etcetera). 9 Audiotapes, In m a n y localities, t e l e m e t r y t a p e s are not s a v e d as a p e r m a n e n t record, b u t m a y be adm i s s i b l e in court if t h e y are available. More commonly, t h e t a p e h a s b e e n t r a n s c r i b e d , a n d t h e w r i t t e n t r a n s c r i p t i o n is e n t e r e d into evidence.
Additional uses of reports Of critical c o n t e m p o r a r y importance, t h e record m a y p r o v i d e b i l l i n g information t h a t facilitates c l a i m s r e v i e w a n d p a y m e n t . Payers w a n t to k n o w t h a t t h e y
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are g e t t i n g v a l u e for their h e a l t h care dollar. Bec a u s e p a y e r s h a v e a c o n t r a c t u a l o b l i g a t i o n to enrollees, t h e y m a y r e q u e s t a d d i t i o n a l d o c u m e n t a t i o n to v a l i d a t e t h a t p r o v i d e d s e r v i c e s w e r e a p p r o p r i a t e to t h e t r e a t m e n t of the p a t i e n t ' s condition, or w e r e m e d i c a l l y n e c e s s a r y for t h e d i a g n o s i s a n d t r e a t m e n t of an illness or injury. I n a d e q u a t e d o c u m e n t a t i o n can l e a d to u n d e r b i l l i n g or c a u s e c h a r g e s to be disa l l o w e d b y t h i r d - p a r t y payers. M a n y of our peers h a v e found, to their dismay, t h a t t e l e m e t r y records b e c o m e court e v i d e n c e in b o t h civil a n d criminal cases. If you have not b e e n n e g l i g e n t , t h e record s h o u l d be your g r e a t e s t ally a n d b e s t defense. A " g o o d " run s h e e t / c h a r t s h o u l d d e f e n d i t s e l f . . , and those who wrote it. A l t h o u g h
M a n y of our p e e r s h a v e found, to their d i s m a y , that telemetry records become court e v i d e n c e in b o t h civil and criminal cases.
the p e r s o n s w h o have g e n e r a l a c c e s s to reports inc l u d e t h e originator, their i m m e d i a t e supervisor, a q u a l i t y i m p r o v e m e n t screener, a n d t h i r d - p a r t y payers, i n v o l v e m e n t in l i t i g a t i o n m a g n i f i e s access to records t h r e e f o l d to fourfold. M e d i c a l records s h o u l d a s s i s t in p r o t e c t i n g the legal i n t e r e s t s of the p a t i e n t and h e a l t h care providers, b u t t h e y can also be the u l t i m a t e d o u b l e - e d g e d sword. In c e r t a i n situations, records provide clinical d a t a for r e s e a r c h a n d e d u c a t i o n . A good e x a m p l e of t h i s i n c l u d e s t r a u m a r e g i s t r y data, which u s u a l l y require a p r e h o s p i t a l t r a u m a score t a k e n from the t e l e m e t r y log or p r e h o s p i t a l record. Retrospective records r e v i e w also a s s i s t s in q u a l i t y control measures such as utilization r e v i e w a n d quality of care evaluations. Law e n f o r c e m e n t p e r s o n n e l m a y use EMS records in i n s t a n c e s of d o m e s t i c violence, child m a l t r e a t m e n t , s e x u a l assault, d y i n g declarations, violent p a t i e n t behavior, u n c o o p e r a t i v e b y s t a n d e r s , c h e m i c a l a b u s e , homicide, a n d a s s a u l t a n d b a t t e r y situations. Social service a g e n c i e s m a y u s e EMS records to a s s i s t d e c i s i o n m a k i n g in i n s t a n c e s such as child m a l t r e a t m e n t , coroner's cases, a n i m a l bites, contagious diseases, involuntary admissions, and e n v i r o n m e n t a l hazards.
Mattera/JOURNAL OF EMERGENCY NURSING
Attributes o f a g o o d medical record S o m e advocate use of the F A C T S y s t e m in documentation in medical charts. Charting information should m e e t the following criteria:
Factual T h e l o g s h o u l d c h r o n i c l e o b j e c t i v e i n f o r m a t i o n reported by emergency medical technicians (EMTs)-w h a t t h e y o b s e r v e a b o u t t h e s c e n e , g l e a n from t h e i r a s s e s s m e n t , or t r e a t m e n t s r e n d e r e d to t h e p a t i e n t . R e s i s t t h e i m p u l s e to s p e c u l a t e , j u d g e c h a r a c t e r , or to l a b e l b e h a v i o r s b y u s i n g s l a n g or d e m e a n i n g statements abbreviated as code initials (such as T N T or PRH). On t h e o t h e r h a n d , u s i n g a p p r o p r i a t e m e d i c a l a b b r e v i a t i o n s i n c r e a s e s t h e a m o u n t of inf o r m a t i o n t h a t c a n b e n o t e d in a l i m i t e d s p a c e a n d in t h e s h o r t t i m e s p a n t a k e n b y m o s t t e l e m e t r y calls. S o m e E M S s y s t e m s h a v e i s s u e d lists of a p p r o v e d a b b r e v i a t i o n s ; b e s u r e to c h e c k y o u r local protocols. C h a r t i n g g e n e r a l l y s h o u l d m a i n t a i n a s e n s e of p r o f e s s i o n a l d e t a c h m e n t . P e r s o n a l r e m a r k s a r e ina p p r o p r i a t e (i.e., I m p r e s s i o n : " A c a d e m y - a w a r d w i n n i n g p e r f o r m a n c e " ) . If a p a t i e n t is p h y s i c a l l y or verb a l l y a b u s i v e , h i s or h e r c o m m e n t s a n d a c t i o n s should be noted as observed facts without labeling t h e b e h a v i o r . S t a t e m e n t s s u c h as, " p a t i e n t d r u n k a n d o b n o x i o u s " s h o u l d n e v e r a p p e a r on t h e record. D e r o g a t o r y or s a r c a s t i c a l l y h u m o r o u s j i b e s a r e l i k e l y to o f f e n d a n d a n g e r a p a t i e n t w h o a s k s to s e e h i s or her record at a later date. U s e q u o t a t i o n m a r k s to i n d i c a t e t h e p a t i e n t ' s a c t u a l w o r d s . T h i s is p a r t i c u l a r l y v a l u a b l e w h e n trying to justify t h a t a p a t i e n t is c o m p e t e n t or incomp e t e n t . A m o t h e r of a r e c e n t l y d e c e a s e d t o d d l e r w a s f o u n d in t h e c r a w l s p a c e of h e r h o m e a b o u t 2 w e e k s b e f o r e C h r i s t m a s , r o c k i n g b a c k a n d forth, c l u t c h i n g t h e d e a d c h i l d ' s coat, t e l l i n g t h e i n f a n t b r o t h e r , " W e ' r e g o i n g to s e e y o u r b r o t h e r for C h r i s t m a s . " T h e s e s t a t e m e n t s on t h e r e c o r d w e r e i n s t r u m e n t a l in h a v i n g h e r a d m i t t e d for a p s y c h i a t r i c e v a l u a t i o n . P a t i e n t n o n c o m p l i a n c e w i t h r e q u e s t s or ins t r u c t i o n s s h o u l d a l s o b e n o t e d , a s in t h e f o l l o w i n g e x a m p l e : " F o u n d p a t i e n t s m o k i n g 15 m i n u t e s after c h e s t t u b e i n s e r t i o n . S m o k e o b s e r v e d in c h e s t d~ainage tube. Patient awake, alert and oriented X3. S h e h a d b e e n i n s t r u c t e d n o t to u s e s m o k i n g m a t e r i a l s prior to c h e s t t u b e i n s e r t i o n . " If a p r o s e c u t i n g a t t o r n e y is t r y i n g to p r o v e p r o x i m a t e c a u s e of damages, a chart that reflects a patient's contribut i o n s to t h e d a m a g e s m a y b e h e l p f u l to t h e d e f e n s e . W h e n p r e s e n t e d w i t h t h e facts, j u r i e s m a y h o l d p a t i e n t s a c c o u n t a b l e for t h e i r o w n n e g l i g e n c e , p r o v i d e d t h a t it c a n b e p r o v e n t h a t t h e y w e r e c o m p e t e n t a t t h e t i m e of t h e i r a c t i o n s (i.e., " E M T s r e p o r t
C & A p a t i e n t r e p e a t e d l y r e m o v i n g c e r v i c a l collar against their advice").
Accurate E v e n f a c t u a l r e c o r d s will b e s u b j e c t to s c r u t i n y if t h e y look i n a c c u r a t e or u n r e l i a b l e . D u r i n g t h e d i s c o v e r y p e r i o d , a t t o r n e y s from b o t h s i d e s will e x a m i n e all c h a r t s or l o g s a n d c o m p a r e t h e a c t u a l n o t a t i o n s to w r i t t e n s t a n d a r d s . E v e r y w o r d a n d t i m e f r a m e m a y b e m e a n i n g f u l . I n a c c u r a t e or i n c o m p l e t e entries, without just cause, diminish the reliability of t h e record. O n c e t h e r e c o r d ' s c r e d i b i l i t y h a s b e e n i m p u g n e d , so h a s t h e r e l i a b i l i t y of t h e MICN. Models for documentation SOAP Method --problem-oriented record S S u b j e c t i v e : The history of the patient: both immediate history and the precipitating events, medications, and reactions. Record things the patient has conveyed. O Objective: What you have found through the assessment, including pertinent positive and negative findings from the primary and secondary survey. A Assessment of the incident as a whole: Not a diagnosis, but rather a general impression of the condition(s) presented. P P l a n of action: Treatment rendered to patient. CHARTE Method - - b r e a k s the run down into logical parts; presents an organized report with full analysis of all available facts. C Chief complaint: Patient's description of incident or problem. H History: The patient's immediate history and any precipitating events; medications. A Assessment: The full primary and secondary assessments. R Rx (Treatment): The treatment that was given before arrival of EMS providers and all that was implemented by them on scene. T Transport: The treatment that was given enroute and the mode of transportation. E Exceptions: The problems that were encountered during the run.
Body Systems Approach--probably most conclusive; but difficultto apply in the field.It is an adaptation of nursing assessments.
MIV Method:--least informative and leaves out vital information. This method presents the incident in a very concise manner. The patient and scene information is noted briefly in logical order such as in mass casualty situations.
Figure 1 Models for EMS documentation. Data from Bevelacqua A. Prehospital documentation: a systematic approach. Englewood Cliffs, New Jersey: Brady, 1992.
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Countersigning A l t h o u g h c o u n t e r s i g n i n g a record d o e s not i m p l y t h a t you h a n d l e d the call or wrote the record, it does verify t h a t you r e v i e w e d the entry(ies), a p p r o v e d t h e s t a t e m e n t s noted, or care given, thereby strengthening the assumption that the record is accurate. If you are a p r e c e p t o r or are r e q u i r e d to c o u n t e r s i g n a n o t h e r ' s d o c u m e n t a t i o n , r e v i e w t h e record thoroughly. M a k e sure it is comp l e t e a n d accurate. If you rely on t h e o r i g i n a t o r ' s c o m p e t e n c y a n d sign hurriedly, or c a r e l e s s l y overlook s u b s t a n d a r d care, you could share l i a b i l i t y for any damages. Complete Ideally, t h e c o m m u n i c a t i o n s log s h o u l d s t a n d alone as a chronologic r e c o r d i n g of all out-of-hospital events. Unfortunately, MICNs rarely h a v e t i m e to note e v e r y t h i n g r e p o r t e d from the field, a n d some areas on the log m a y be left s u s p i c i o u s l y e m p t y . To the b e s t of y o u r ability, avoid l e a v i n g b l a n k s p a c e s on the record u n l e s s local protocols clearly allow for c h a r t i n g b y exception. It is helpful if b o x e s are p r e s e n t t h a t allow quick c h e c k m a r k s n o t i n g e i t h e r " w i t h i n n o r m a l l i m i t s " or other locally c u s t o m i z e d n o t a t i o n s s u g g e s t i n g a p a t h o l o g i c c o n d i t i o n (nausea, v o m i t i n g , cough, etc.) E q u a l l y helpful are check b o x e s for r o u t i n e a s s e s s m e n t s , such as quantification of pain, p u p i l size a n d reactivity, b r e a t h sounds, skin color, t e m p e r a t u r e , moisture, level of consciousness, G l a s g o w C o m a Scale scores a n d t r a u m a scores. F o r m s c o n s t r u c t e d to facilitate quick n o t a t i o n s of care r e n d e r e d in t h e field, d e s t i n a t i o n , a n d estim a t e d t i m e of arrival are also b e n e f i c i a l p r o v i d e d local protocols define t h e a p p l i c a b l e s t a n d a r d s of practice. It will be a r g u e d t h a t if records are e r r o n e o u s in one r e s p e c t t h a t t h e y also are faulty in others. If the record does not s u b s t a n t i a t e your claim, it will be difficult to convince a jury t h a t your m e m o r y of dist a n t e v e n t s is superior to your w r i t t e n n o t a t i o n s r e n d e r e d at t h e time. Do not try to cover up an embarrassing fact It is a l w a y s p r e f e r a b l e to disclose d a m a g i n g or e m b a r r a s s i n g information, such as a m e d i c a t i o n d o s a g e error. The fact t h a t an error w a s m a d e d o e s not a u t o m a t i c a l l y i m p l y n e g l i g e n c e . The p a t i e n t m u s t suffer d a m a g e s , a n d t h e p r o x i m a t e c a u s e of the d a m a g e s m u s t be p r o v e n before an a l l e g a t i o n of n e g l i g e n c e is generally s u s t a i n e d . Timely The MICN s h o u l d d o c u m e n t as m u c h as p o s s i b l e d u r i n g t h e run. If this c a n n o t be d o n e contempora~ neously, jot d o w n s h o r t h a n d notes so t h a t d e t a i l s
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r e m a i n fresh until you can finish t h e record. All vital signs, r h y t h m i n t e r p r e t a t i o n s , a s s e s s m e n t s , a n d out-of-hospital i n t e r v e n t i o n s s h o u l d b e t i m e d u n l e s s local protocols i n d i c a t e otherwise. C o m m o n errors on t e l e m e t r y logs i n c l u d e e s t i m a t i n g t i m e s for the a b o v e - m e n t i o n e d d a t a sets. MICNs q u e s t i o n w h e t h e r t h e y s h o u l d note t h e t i m e t h e report w a s c a l l e d in or w h e n the EMTs m a y h a v e o b t a i n e d t h e information. Local s t a n d a r d s s h o u l d s t i p u l a t e w h i c h t i m e s h o u l d b e recorded. It is confusing if the preh o s p i t a l run s h e e t lists different t i m e s a n d interv e n t i o n s t h a n t h e t e l e m e t r y log. Who s h o u l d be believed? One solution is to h a v e a box t h a t i n d i c a t e s "prior to c a l l i n g " (PTC). This m e t h o d allows an MICN to note those a s s e s s m e n t s or i n t e r v e n t i o n s t h a t w e r e c o m p l e t e d b y EMTs before e s t a b l i s h i n g
H a v e a b o x that i n d i c a t e s "prior to c a l l i n g " (PTC). This m e t h o d a l l o w s a n MICN to n o t e t h o s e a s s e s s m e n t s or interventions that were completed by EMTs before establishing communication.
c o m m u n i c a t i o n , at t i m e s n o t e d b y t h e m on their run sheet. It also h e l p s to d i s t i n g u i s h the a s p e c t s of a call t h a t w e r e carried out by EMTs u n d e r s t a n d i n g m e d i c a l orders v e r s u s the d i r e c t m e d i c a l control of an MICN. Therefore t i m e s on t h e n u r s e ' s log u s u a l l y i n d i c a t e e i t h e r the t i m e he or she w a s first a w a r e of field d a t a or t h e point at w h i c h further orders w e r e initiated. An a t t o r n e y m a y u n d e r m i n e t h e reliability a n d a c c u r a c y of your m e d i c a l control b y q u e s t i o n i n g the t i m e l i n e s s of your orders. T r a n s c r i p t s from a r e c e n t d e p o s i t i o n i l l u s t r a t e this point. The following d i a l o g reflects t h e q u e s t i o n i n g of a t e l e m e t r y nurse b y the plaintiff's a t t o r n e y w i t h r e s p e c t to her h a n d l i n g of an out-of-hospital b r e e c h birth: 0 . "Okay. This w a s a b r e e c h birth?" A . " T h a t ' s correct." O. " A n d you k n e w that at the very start of the con versa tion ?" A . " T h a t ' s correct."
Ma~tera/JOURNALOF EMERGENCY NURSING
Oo " W h y did you n o t tell the p a r a m e d i c s to imm e d i a t e l y g e t that b a b y to the hospital?" A , "Birth w a s i m m i n e n t . " 0 . "Birth w a s i m m i n e n t ? " A , "Birth w a s in progression. A n d you don't imm e d i a t e l y bring a b a b y that is b e i n g delivered right to the hospital. You proceed and try to deliver that baby." More q u e s t i o n s followed: O, "Do you k n o w that a h a f f hour w e n t b y from the time the p a r a m e d i c s arrived to the time of arrivai at the hospital?" A , "I don't k n o w . " 0 , "You don't k n o w that or do you k n o w that?" A . "The only w a y I k n o w that is b y the p a r a m e d i c run s h e e t . " More q u e s t i o n s . . . . it is e s t a b l i s h e d t h a t t h e n u r s e h a d s p o k e n b y t e l e p h o n e w i t h an o b s t e t r i c i a n to s e e k a d d i t i o n a l d i r e c t i o n a n d t h a t an e m e r g e n c y p h y s i c i a n w a s at her side. O, " H o w long did your conversation with Dr. X take total?" A . "'I den't h a v e a n y idea." O. "You said you were g e t t i n g directions from Dr. Y. Apparently, you were also g e t t i n g directions from Dr. X?" A , "Just from the one p h o n e conversation." Q. "Which c o n s i s t e d of h o w m a n y q u e s t i o n s a s k e d of Dr. X ? " A . "I don't r e m e m b e r h o w m a n y q u e s t i o n s there actually w e r e . " 0 . " A n d the course you took in regard to b e c o m i n g certified as an e m e r g e n c y room nurse, part of which pertained to birth deliveries. Did you r e c e i v e instruction that in the e v e n t of a b r e e c h delivery out in the field that if there w a s time to g e t the m o t h e r to the hospital s h e should b e transported q u i c k l y to the hospital?" 0 , "You g a v e a n u m b e r of directions in regard to the birth, all of which took time, a p p r o x i m a t e l y h a f t an hour. Can you give m e a reason w h y you didn't insist on those p a r a m e d i c s covering those 2 to 3 m i l e s to the hospital with that m o t h e r and that partially delivered b a b y ? " As you can see, e x a m i n a t i o n u n d e r o a t h in a d e p o s i t i o n m a y b e a g o n i z i n g a n d ask far more t h a n c a s u a l notes m i g h t record. This nurse d i d a s u p e r b job in d i r e c t i n g this difficult run, b u t the a t t a c k on her a b i l i t y a n d c r e d i b i l i t y w a s scathing. The MICN m u s t be as specific as p o s s i b l e in verbal d i r e c t i o n s a n d in d o c u m e n t i n g orders to h e l p aid later recollection of e v e n t s - - t h e d i r e c t i o n s a n d orders s h o u l d b e t i m e d w h e n e v e r possible.
L e g i b l e h a n d w r i t i n g s h o u l d b e a d d e d to t h e criteria for good charting. There s h o u l d be no d o u b t a b o u t w h a t is written. A p a r a m e d i c once told me t h a t he m a k e s his s i g n a t u r e i l l e g i b l e so no one could ever prove he w a s on a call. Such m a g i c a l thinkingr The chart reflects your professional c o m p e t e n c y and, in m a n y ways, your p e r s o n a l style a n d values. M i s s p e l l e d words, s c r a w l e d h a n d w r i t i n g , incorrectly u s e d m e d i c a l t e r m i n o l o g y ( c h a r t i n g CheyneStokes v e n t i l a t i o n s w h e n t h e y w e r e a c t u a l l y ataxic), a n d u s i n g n o n s t a n d a r d a b b r e v i a t i o n s are c h a r t i n g n i g h t m a r e s t h a t m a y later h a u n t you. If you c a n n o t r e a d your own report, the jury m a y not be w i l l i n g to b e l i e v e your v e r b a l testimony. In a close decision, a jury m a y a s s u m e t h a t s l o p p y c h a r t i n g i n d i c a t e s s l o p p y care.
Minimum communication log documentation The m i n i m u m d a t a r e q u i r e d for out-of-hospital log d o c u m e n t a t i o n i n c l u d e the following: 9 Call d a t e a n d time 9 Identification of the EMS a g e n c y / v e h i c l e 9 P a t i e n t identification: age, gender, weight, initials 9 P e r t i n e n t h i s t o r y of p r e s e n t i l l n e s s / i n j u r y , r e l e v a n t p a s t m e d i c a l history 9 Chief a n d a s s o c i a t e d complaints; quantify p a i n / d i s t r e s s on a scale of 0 to 10 9 Patient a s s e s s m e n t findings: chronologic notation of scene survey, physical assessments, vital signs, a n d all other relevant observations 9 Results of d i a g n o s t i c t e s t s such as capillary glucose r e a d i n g s a n d EKG r h y t h m 9 Care r e n d e r e d before arrival 9 A n y h o s p i t a l - g e n e r a t e d orders 9 Clinical o b s e r v a t i o n s i n c l u d i n g r e s p o n s e s to i n t e r v e n t i o n s , w h i c h are as i m p o r t a n t as the i n t e r v e n t i o n itself 9 Final d i s p o s i t i o n a n d e s t i m a t e d time of arrival 9 For t r a u m a p a t i e n t s : m e c h a n i s m s of injury, G l a s g o w C o m a Scale score, a n d t r a u m a scores; r e s c u e / e x t r i c a t i o n information 9 F a c t s s u p p o r t i n g the i n t e n s i t y of t h e p a t i e n t evaluation and treatment, including thought p r o c e s s e s a n d t h e c o m p l e x i t y of m e d i c a l decision m a k i n g 9 L e g i b l e s i g n a t u r e ( s ) a n d n a m e s of m e d i c a l control p e r s o n n e l 9 C o m m u n i c a t i o n method: t e l e m e t r y (UHF) radio, VHF radio, phone, or cellular phone; q u a l i t y / c l a r i t y of t r a n s m i s s i o n s 9 Notation of other a g e n c i e s on s c e n e (i.e., police)
June 199.~
~I;~
JOURNAL OF EMERGENCY NURSINQ/Mattera
Refer to local protocols for the m i n i m u m d a t a s e t s in your area.
Amending a record R e p o r t s w i t h o b v i o u s c h a n g e s b u t w i t h o u t approp r i a t e n o t a t i o n s are suspect. A n y a l t e r a t i o n s s h o u l d b e a c c o m p a n i e d b y an e x p l a n a t i o n a n d t h e d a t e of t h e c h a n g e . The p r e v i o u s entry s h o u l d still be r e a d a b l e . Do not d i s c a r d a n y original records or recopy t h e log. Do not b a c k d a t e a n y records. If it app e a r s t h a t you h a v e a l t e r e d or o t h e r w i s e t a m p e r e d w i t h a notation, it r a i s e s q u e s t i o n s a b o u t t h e n a t u r e of t h e r e v i s e d entry, t h e l o g ' s accuracy, a n d your honesty. To a p p r o p r i a t e l y correct an error in a report, d r a w a s t r a i g h t line t h r o u g h t h e m i s t a k e so t h a t it r e m a i n s legible. Write "incorrect entry," "disreg a r d , " or "error" a b o v e or b e s i d e the original entry, sign your n a m e or initials, a n d d a t e t h e c h a n g e . At t h e n e x t a v a i l a b l e spot in t h e record, a n e w note, d a t e d a n d s i g n e d , s h o u l d be w r i t t e n to e x p l a i n the n e e d for t h e correction. If it is n e c e s s a r y to record more information, a s u p p l e m e n t a l r e p o r t - - c l e a r l y i n d i c a t e d as a late e n t r y - - s h o u l d be recorded. It s h o u l d b e d a t e d , c o n t a i n t h e r a t i o n a l e for t h e a d d i tions, a n d t h e s i g n a t u r e of t h e p e r s o n w h o m a d e them. Never a t t e m p t to d e l e t e information or alter exi s t i n g d o c u m e n t s after l e g a l action h a s b e e n initiated. Falsification of r e c o r d s is e v i d e n c e of "cons c i o u s n e s s of n e g l i g e n c e . " If s u b p o e n a is i s s u e d for use of t h e records for information, tl~e r e q u e s t e d d o c u m e n t s s h o u l d be r e v i e w e d b y t h e h o s p i t a l ' s att o r n e y to d e t e r m i n e w h e t h e r a s u p p l e m e n t a l report s h o u l d be created.
Checklist for d o c u m e n t a t i o n As you q u i c k l y scan your l o g , ask yourself the following questions: 9 Does t h e record c o n t a i n all t h e information n e e d e d b y yourself a n d others w h o m a y rely on t h e record? Like a story, a report n e e d s a logical b e g i n n i n g , m i d d l e , a n d conclusion. 9 Does your record a d e q u a t e l y s t a t e all of the E M T ' s r e p o r t e d o b s e r v a t i o n s a b o u t t h e patient? Are t i m e s l i s t e d n e x t to all o b s e r v a t i o n s or i n t e r v e n t i o n s ? 9 Does t h e record list all out-of-hospital treatm e n t ( s ) g i v e n a n d the p a t i e n t ' s r e s p o n s e s ? 9 Does t h e t r e a t m e n t fit t h e r e p o r t e d observations a b o u t t h e p a t i e n t w i t h i n the a e g i s of local s t a n d i n g m e d i c a l orders?
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9 Is t h e record c o m p l e t e e n o u g h so t h a t you could m e n t a l l y r e c o n s t r u c t t h e e n t i r e call a n d d e f e n d your a c t i o n s at a later d a t e if you w e r e r e q u i r e d to do so? 9 Do your records conform to t h e d e t a i l dem a n d e d by your local s t a n d a r d s of practice (e.g., t i m i n g of vital signs, c o m p l e t e n e s s of assessments)? 9 Does t h e record i n c l u d e a l e g i b l e signature w i t h c r e d e n t i a l s a u t h e n t i c a t i n g the record?
Documentation tips 9 D o c u m e n t in b l a c k ink. Black is g e n e r a l l y u s e d to d e n o t e a legal record a n d p r o d u c e s c o p i e s t h a t are more e a s i l y r e a d a b l e , w h i c h is often n e c e s s a r y if t h e c h a r t is going to be microfilmed. Further, some of t h e n e w c o m p u t e r s c a n n e r s will not r e a d colored inks. 9 Press hard if the record is p r i n t e d on mult i p a g e c a r b o n l e s s p a p e r so all copies all legible. 9 D o c u m e n t s i g n s a n d s y m p t o m s as r e p o r t e d b y EMTs. Use a p a t i e n t ' s o w n w o r d s w h e n ever possible. E n c a s e q u o t e s in q u o t a t i o n marks. 9 D o c u m e n t a n y i n t e r v e n t i o n s i n i t i a t e d by EMTs or o r d e r e d b y t h e b a s e station a n d the p a t i e n t ' s r e s p o n s e s to t h e i n t e r v e n t i o n if t h a t information is k n o w n before the a m b u l a n c e arrives at t h e hospital. 9 D o c u m e n t e n o u g h i n f o r m a t i o n to d r a w logical conclusions a b o u t t h e a p p r o p r i a t e n e s s of out-of-hospital care. 9 The p e r s o n s c r e a t i n g t h e d o c u m e n t m u s t be i d e n t i f i e d b y n a m e a n d c r e d e n t i a l s , w i t h legible signature. Consult local policy w i t h reg a r d to t h e n e c e s s i t y of p r e c e p t o r or p h y s i c i a n co-signers.
Summary All MICNs m u s t m a i n t a i n a h i g h d e g r e e of commitment, b o t h to their c o m p e t e n c y to p r o v i d e quality m e d i c a l control for out-of-hospital calls a n d the p r a c t i c e of quality d o c u m e n t a t i o n . G e n e r a t i n g a leg a l l y d e f e n s i b l e c o m m u n i c a t i o n s log is a skill req u i r i n g more a t t e n t i o n to d e t a i l t h a n it often receives. MICNs n e e d to a p p r e c i a t e t h a t a legal record is b e i n g c r e a t e d t h a t m a y b e s u b p o e n a e d in t h e s a m e m a n n e r as ED charts. The b e s t m a l p r a c t i c e i n s u r a n c e a v a i l a b l e is an e m e r g e n c y record prep a r e d so t h a t it is l e g a l l y c a p a b l e of s t a n d i n g on its o w n merit.
Mattera/JOURNAL OF EMERGENCY NURSING Suggested readings Bergerson S. Charting with a jury in mind. Nurs Life 1982;July-Aug:30-3. Bergerson S. More about charting with a jury in mind. Nursing 88 1988;April:51-6. Bevelacqua A. Prehospital documentation: a systematic approach. Englewood Cliffs, New Jersey: Brady, 1992. Fosarelli P, Baker MD. What you don't record can hurt you: documentation in the emergency department. Pediatric Emergency Care 1985; 1:223-7. George J, Quattrone M, eds. Documentation: the most important tool. Emergency Physician Legal Bulletin 17(1):1-5. George J, Quattrone M, eds. The emergency department medical record. 18(2):1-7. Lampe B. 10 steps to writing better run reports. Emergency 1991;Oct:37-41.
Mandell M. Charting: how it can keep you o u t of court. Nurs Life 1987;Sept-Oct:46-8. Mourafetis D. Principles of medical record documentation. Unpublished hospital inservice handout. Arlington Heights, Northwest Community Hospital. Murphy J, Beglinger J, Johnson B. Charting by exception: meeting the challenge of cost containment. Nurs Mana g e m e n t 1988;19:56-72. Nagorka F. Documentation, the only protection. Lecture outline 1992. Schaller J. Documentation of nursing care. N u t s Spectrum 1991;Aug 5:17. Southard P. Trauma care documentation: a comprehensive guide. J EMERG NURS 1989;15:393-8. Tammelleo AD. Ed. Rx: avoid "speculation" and "admissions" in charting. Regan Report on Nursing Law 1990; 30:2.
1 l t h o u g h t h e r e h a d b e e n a s l o w d o w n in t h e form a t i o n of n e w air m e d i c a l p r o g r a m s d u r i n g t h e p a s t s e v e r a l y e a r s , r e c e n t l y t h e r e h a s b e e n a flurry of a c t i v i t y (at l e a s t in t h e N o r t h e a s t ) a s h o s p i t a l s - especially those hospitals that are regional referral h o s p i t a l s in r u r a l a r e a s - - c o n s i d e r s t a r t i n g p r o g r a m s . T h i s s e r i e s of a r t i c l e s is d e s i g n e d to a s s i s t h o s p i t a l s t h a t a r e c o n t e m p l a t i n g a n e w air m e d i c a l p r o g r a m .
A
Needs assessment Before a n y n e w p r o g r a m s t a r t - u p , a n e e d s a s s e s s m e n t s h o u l d b e c o n d u c t e d to d e t e r m i n e t h e a c t u a l n e e d for a p r o g r a m in y o u r r e g i o n . T h i s a s s e s s m e n t s h o u l d i n c l u d e a p r o j e c t i o n of t h e n u m b e r s a n d t y p e s of p a t i e n t s w h o w o u l d b e t r a n s p o r t e d b y air. Gather data about patients previously transported b y g r o u n d units, t h e c a t e g o r y of t h o s e p a t i e n t s (cardiac, t r a u m a , p e d i a t r i c , etc. ), t h e p r e v i o u s t r a n s p o r t t i m e s b y g r o u n d , t h e n u m b e r s of i n s t i t u t i o n s / a g e n -
c i e s t h a t w o u l d u s e y o u r service, a n d t h e p r o b l e m s and patient complications associated with lengthy transport times that could be greatly reduced by a m o r e r a p i d m o d e of t r a n s p o r t a t i o n . Be s u r e to include the problems faced by a community when its o n l y a m b u l a n c e is d i s p a t c h e d for a l e n g t h y p a t i e n t t r a n s p o r t to a t e r t i a r y c e n t e r m a n y m i l e s a w a y a n d t h e d i f f i c u l t y t h e y m a y e n c o u n t e r in findi n g a d v a n c e d life s u p p o r t p e r s o n n e l for t h e t r a n s port. Your d a t a s h o u l d a l s o i n c l u d e t h e e s t i m a t e d n u m b e r of d a y s t h a t y o u r p r o g r a m w o u l d b e una v a i l a b l e b e c a u s e of w e a t h e r a n d o t h e r factors. It s h o u l d i n c l u d e a n a n a l y s i s of t h e r a n g e a n d o v e r l a p t h a t w o u l d o c c u r w i t h o t h e r p r o g r a m s in y o u r For reprints~ write Susan Budassi Sheehy, RN, MSN, CEN, FAAN, 163 Lyme Rd, Hanover, NH 03756. J EMERONURS 1995;21:237-9 Copyright 9 1995 by the Emergency Nurses Association. 0099-1767/95 $3.00 + 0 18/62/64127
June 1995 ~ 7
p o t e n s i o n , c o n g e s t i v e h e a r t failure, b r o n c h o s p a s m , a n d v e n t r i c u l a r d y s r h y t h m i a s . 1~ If t h e s e occur, sotalol t h e r a p y s h o u l d b e d i s c o n t i n u e d i m m e d i a t e l y a n d t h e i n t e r v e n t i o n s d e s c r i b e d in T a b l e 1 are s u g g e s t e d . 10
Summary Sotalol r e p r e s e n t s a n e w a n d b e n e f i c i a l t h e r a p e u t i c a l t e r n a t i v e for t h e t r e a t m e n t of l i f e - t h r e a t e n i n g ventricular dysrhythmias. With the rapid emerg e n c e of t h e s e n e w p h a r m a c e u t i c a l a g e n t s , it is imp o r t a n t t h a t e m e r g e n c y n u r s e s b e c o m e familiar w i t h b o t h t h e b e n e f i c i a l a n d a d v e r s e effects of t h e s e drugs.
References 1. Hohnloser SH, Woosley RL. Sotalol. N Engl J Med 1994;331:31-8. 2. Suttorp MJ, Kingma JH, Peels HOJ, et al. Effectiveness of sotalol in preventing supraventricular tachyarrhythmias shortly after coronary-artery bypass grafting. Am J Cardiol 1991;68:1163-9. 3. Kaumann A J, Aramendia P. Prevention of ventricular fibrillation induced by coronary ligation. J Pharmacol Exp Ther 1968;164:326-32.
Sometimes t h e p r o c e s s of r e v i e w i n g EMS r u n s h e e t s b r i n g s a c h u c k l e to a n o t h e r w i s e h e c t i c day. R e c e n t l y I s a w a n e n t r y t h a t r e a d like this:
CC: "Paper girl passing b y house. Reported unconscious individual in auto with engine running." Comments; "On arrival, found two n a k e d adults in auto e n g a g e d in sexual activities. Neither appeared to b e in any distress and w e returned to quarters." Not your o r d i n a r y c a l l . . , b u t t h e p o i n t at w h i c h w e b e c o m e laissez-faire a b o u t r o u t i n e c a s e s is t h e m o m e n t w h e n our e d g e is lost a n d w e are in d a n g e r
4. Carmeliet E. Electrophysiologic and voltage clamp analysis of the effects of sotalol on isolated cardiac muscle and Purkinje fibers. J Pharmacol Exp Ther 1985; 232:817-25. 5. Touboul P, Atallah G, Krikorian G, et al. Clinical electrophysiology of intravenous sotalol, a beta-blocking drug with class III antiarrhythmic properties. Am Heart J 1984;107:888-95. 6. Antonaccio M J, Gomoll A. Pharmacology, pharmacodynamics and pharmacokinetics of sotalol. Am J Cardiol 1990;65(Suppl): 12A-21A. 7. Schnelle K, Klein G, Schinz A. Studies on the pharmacokinetics and pharmacodynamics of the beta-adrenergic blocking sotalol in normal man. J Clin Pharmacol 1979; 19:516-22. 8. Sundquist H. Basic review and comparison of betablocker pharmacokinetics. Curt Ther Res 1980;28(Suppl):385-445. 9. Berglund G, Descamps R, Thomis JA. Pharmacokinetics of sotalol after chronic administration to patients with renal insufficiency. Eur J Clin Pharmacot 1980; 18:321-6. 10. Product information. Betapace (sotalol hydrochloride). Berlex Laboratories: Wayne, New Jersey, 1993. 11. American Hospital Formulary Service Drug Information. Bethesda, Maryland: American Society of Hospital Pharmacists, 1994:1062-66.
of m a k i n g m i s t a k e s . R e c e n t c o n t i n u o u s q u a l i t y imp r o v e m e n t m o n i t o r s in our EMS s y s t e m reveal t h a t q u a l i t y a n d a p p r o p r i a t e n e s s of care are not q u e s t i o n e d as often as t h e t h o r o u g h n e s s a n d accuracy of the docu m e n t a t i o n of t h a t care. Some m o b i l e i n t e n s i v e care n u r s e s (MICNs) m i g h t n o t realize t h a t they m a y b e leFor reprints, write Connie Mattera, RN, MS, CEN, EMT-P, c/o Northwest Community Hospital, 800 W. Central, Arlington Heights, IL 60065. J EMERGNURS1995;21:231-7 Copyright 9 1995 by the Emergency Nurses Association. 0099-1767/95 $3.00 4- 0
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JOURNALOF EMERGENCYNURSING/Mattera gally vulnerable if their documentation on telemetry radio (communications) logs is substandard. T h e log is only a " s c r a t c h p a d , " not p a r t of a formal record, a n d only s e e n b y MICNs, right? Wrongt In l e g a l terms, after a jury h a s d e t e r m i n e d w h a t t h e s t a n d a r d of care is, it m u s t r e v i e w t h e facts s u b m i t t e d as e v i d e n c e a n d d e c i d e w h e t h e r the MICN m e t t h a t s t a n d a r d . To m a k e t h a t decision, e a c h i n c i d e n t m u s t be reconstructed. P r e d i c t a b l y , l a w y e r s s u b m i t charts, run sheets, or t e l e m e t r y logs into t h e record. C o m p e t e n t l a w y e r s will scrutinize all s a l i e n t reports before i n i t i a t i n g suit. As we h a v e learned, sins of omission are as b a d as t h o s e of commission; t h a t is, t h e failure to i n c l u d e r e l e v a n t i n f o r m a t i o n in the m e d i c a l record can be as d a m n i n g as t h e information i n c l u d e d . The infere n c e s d r a w n b y a jury from t h e information pres e n t e d w e i g h s h e a v i l y on t h e c a s e ' s outcome. The G o l d e n Rule of D o c u m e n t a t i o n can b e s u c c i n c t l y s t a t e d as, " W o u l d the d o c u m e n t c r e a t e d at the t i m e of t h e call a i d in r e c r e a t i n g the run in t h e future?" Reports are often u s e d to jog or r e p l a c e m e m o r y of an incident. Jurors n a t u r a l l y v i e w w i t n e s s e s ' m e m ories as less t h a n r e l i a b l e b e c a u s e c a s e s are not tried for m o n t h s to y e a r s after t h e incident. If you are n a m e d in a suit, it is a s s u m e d t h a t you will h a v e s e l f - s e r v i n g r e c o l l e c t i o n s of facts. Therefore w r i t t e n d o c u m e n t a t i o n is the m o s t r e l i a b l e e v i d e n c e of w h a t d i d (or d i d not) h a p p e n . F i g u r e 1 p r o v i d e s several d o c u m e n t a t i o n models.
Admissible documents authenticating out-of-hospital medical control 9 Personal notes. S c r i b b l e s on n o t e p a d s are c o m m o n d u r i n g an u n e x p e c t e d call. If t h e s e are saved, t h e y m a y be e n t e r e d into the record.
9 Preprinted standard forms (communications log). There is no single, perfect m e d i c a l record form. The c o n t e n t s a n d c o n s t r u c t i o n often d e p e n d on local preference, a l t h o u g h s t a n d a r d d a t a sets for hospitals have been established through national g u i d e l i n e s (Joint C o m m i s s i o n on A c c r e d i t a t i o n of H e a l t h c a r e Organizations), a n d s t a n d a r d d a t a sets for out-of-hospital p r o v i d e r s h a v e b e e n e s t a b l i s h e d at t h e federal level (Etcetera). 9 Audiotapes, In m a n y localities, t e l e m e t r y t a p e s are not s a v e d as a p e r m a n e n t record, b u t m a y be adm i s s i b l e in court if t h e y are available. More commonly, t h e t a p e h a s b e e n t r a n s c r i b e d , a n d t h e w r i t t e n t r a n s c r i p t i o n is e n t e r e d into evidence.
Additional uses of reports Of critical c o n t e m p o r a r y importance, t h e record m a y p r o v i d e b i l l i n g information t h a t facilitates c l a i m s r e v i e w a n d p a y m e n t . Payers w a n t to k n o w t h a t t h e y
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are g e t t i n g v a l u e for their h e a l t h care dollar. Bec a u s e p a y e r s h a v e a c o n t r a c t u a l o b l i g a t i o n to enrollees, t h e y m a y r e q u e s t a d d i t i o n a l d o c u m e n t a t i o n to v a l i d a t e t h a t p r o v i d e d s e r v i c e s w e r e a p p r o p r i a t e to t h e t r e a t m e n t of the p a t i e n t ' s condition, or w e r e m e d i c a l l y n e c e s s a r y for t h e d i a g n o s i s a n d t r e a t m e n t of an illness or injury. I n a d e q u a t e d o c u m e n t a t i o n can l e a d to u n d e r b i l l i n g or c a u s e c h a r g e s to be disa l l o w e d b y t h i r d - p a r t y payers. M a n y of our peers h a v e found, to their dismay, t h a t t e l e m e t r y records b e c o m e court e v i d e n c e in b o t h civil a n d criminal cases. If you have not b e e n n e g l i g e n t , t h e record s h o u l d be your g r e a t e s t ally a n d b e s t defense. A " g o o d " run s h e e t / c h a r t s h o u l d d e f e n d i t s e l f . . , and those who wrote it. A l t h o u g h
M a n y of our p e e r s h a v e found, to their d i s m a y , that telemetry records become court e v i d e n c e in b o t h civil and criminal cases.
the p e r s o n s w h o have g e n e r a l a c c e s s to reports inc l u d e t h e originator, their i m m e d i a t e supervisor, a q u a l i t y i m p r o v e m e n t screener, a n d t h i r d - p a r t y payers, i n v o l v e m e n t in l i t i g a t i o n m a g n i f i e s access to records t h r e e f o l d to fourfold. M e d i c a l records s h o u l d a s s i s t in p r o t e c t i n g the legal i n t e r e s t s of the p a t i e n t and h e a l t h care providers, b u t t h e y can also be the u l t i m a t e d o u b l e - e d g e d sword. In c e r t a i n situations, records provide clinical d a t a for r e s e a r c h a n d e d u c a t i o n . A good e x a m p l e of t h i s i n c l u d e s t r a u m a r e g i s t r y data, which u s u a l l y require a p r e h o s p i t a l t r a u m a score t a k e n from the t e l e m e t r y log or p r e h o s p i t a l record. Retrospective records r e v i e w also a s s i s t s in q u a l i t y control measures such as utilization r e v i e w a n d quality of care evaluations. Law e n f o r c e m e n t p e r s o n n e l m a y use EMS records in i n s t a n c e s of d o m e s t i c violence, child m a l t r e a t m e n t , s e x u a l assault, d y i n g declarations, violent p a t i e n t behavior, u n c o o p e r a t i v e b y s t a n d e r s , c h e m i c a l a b u s e , homicide, a n d a s s a u l t a n d b a t t e r y situations. Social service a g e n c i e s m a y u s e EMS records to a s s i s t d e c i s i o n m a k i n g in i n s t a n c e s such as child m a l t r e a t m e n t , coroner's cases, a n i m a l bites, contagious diseases, involuntary admissions, and e n v i r o n m e n t a l hazards.
Mattera/JOURNAL OF EMERGENCY NURSING
Attributes o f a g o o d medical record S o m e advocate use of the F A C T S y s t e m in documentation in medical charts. Charting information should m e e t the following criteria:
Factual T h e l o g s h o u l d c h r o n i c l e o b j e c t i v e i n f o r m a t i o n reported by emergency medical technicians (EMTs)-w h a t t h e y o b s e r v e a b o u t t h e s c e n e , g l e a n from t h e i r a s s e s s m e n t , or t r e a t m e n t s r e n d e r e d to t h e p a t i e n t . R e s i s t t h e i m p u l s e to s p e c u l a t e , j u d g e c h a r a c t e r , or to l a b e l b e h a v i o r s b y u s i n g s l a n g or d e m e a n i n g statements abbreviated as code initials (such as T N T or PRH). On t h e o t h e r h a n d , u s i n g a p p r o p r i a t e m e d i c a l a b b r e v i a t i o n s i n c r e a s e s t h e a m o u n t of inf o r m a t i o n t h a t c a n b e n o t e d in a l i m i t e d s p a c e a n d in t h e s h o r t t i m e s p a n t a k e n b y m o s t t e l e m e t r y calls. S o m e E M S s y s t e m s h a v e i s s u e d lists of a p p r o v e d a b b r e v i a t i o n s ; b e s u r e to c h e c k y o u r local protocols. C h a r t i n g g e n e r a l l y s h o u l d m a i n t a i n a s e n s e of p r o f e s s i o n a l d e t a c h m e n t . P e r s o n a l r e m a r k s a r e ina p p r o p r i a t e (i.e., I m p r e s s i o n : " A c a d e m y - a w a r d w i n n i n g p e r f o r m a n c e " ) . If a p a t i e n t is p h y s i c a l l y or verb a l l y a b u s i v e , h i s or h e r c o m m e n t s a n d a c t i o n s should be noted as observed facts without labeling t h e b e h a v i o r . S t a t e m e n t s s u c h as, " p a t i e n t d r u n k a n d o b n o x i o u s " s h o u l d n e v e r a p p e a r on t h e record. D e r o g a t o r y or s a r c a s t i c a l l y h u m o r o u s j i b e s a r e l i k e l y to o f f e n d a n d a n g e r a p a t i e n t w h o a s k s to s e e h i s or her record at a later date. U s e q u o t a t i o n m a r k s to i n d i c a t e t h e p a t i e n t ' s a c t u a l w o r d s . T h i s is p a r t i c u l a r l y v a l u a b l e w h e n trying to justify t h a t a p a t i e n t is c o m p e t e n t or incomp e t e n t . A m o t h e r of a r e c e n t l y d e c e a s e d t o d d l e r w a s f o u n d in t h e c r a w l s p a c e of h e r h o m e a b o u t 2 w e e k s b e f o r e C h r i s t m a s , r o c k i n g b a c k a n d forth, c l u t c h i n g t h e d e a d c h i l d ' s coat, t e l l i n g t h e i n f a n t b r o t h e r , " W e ' r e g o i n g to s e e y o u r b r o t h e r for C h r i s t m a s . " T h e s e s t a t e m e n t s on t h e r e c o r d w e r e i n s t r u m e n t a l in h a v i n g h e r a d m i t t e d for a p s y c h i a t r i c e v a l u a t i o n . P a t i e n t n o n c o m p l i a n c e w i t h r e q u e s t s or ins t r u c t i o n s s h o u l d a l s o b e n o t e d , a s in t h e f o l l o w i n g e x a m p l e : " F o u n d p a t i e n t s m o k i n g 15 m i n u t e s after c h e s t t u b e i n s e r t i o n . S m o k e o b s e r v e d in c h e s t d~ainage tube. Patient awake, alert and oriented X3. S h e h a d b e e n i n s t r u c t e d n o t to u s e s m o k i n g m a t e r i a l s prior to c h e s t t u b e i n s e r t i o n . " If a p r o s e c u t i n g a t t o r n e y is t r y i n g to p r o v e p r o x i m a t e c a u s e of damages, a chart that reflects a patient's contribut i o n s to t h e d a m a g e s m a y b e h e l p f u l to t h e d e f e n s e . W h e n p r e s e n t e d w i t h t h e facts, j u r i e s m a y h o l d p a t i e n t s a c c o u n t a b l e for t h e i r o w n n e g l i g e n c e , p r o v i d e d t h a t it c a n b e p r o v e n t h a t t h e y w e r e c o m p e t e n t a t t h e t i m e of t h e i r a c t i o n s (i.e., " E M T s r e p o r t
C & A p a t i e n t r e p e a t e d l y r e m o v i n g c e r v i c a l collar against their advice").
Accurate E v e n f a c t u a l r e c o r d s will b e s u b j e c t to s c r u t i n y if t h e y look i n a c c u r a t e or u n r e l i a b l e . D u r i n g t h e d i s c o v e r y p e r i o d , a t t o r n e y s from b o t h s i d e s will e x a m i n e all c h a r t s or l o g s a n d c o m p a r e t h e a c t u a l n o t a t i o n s to w r i t t e n s t a n d a r d s . E v e r y w o r d a n d t i m e f r a m e m a y b e m e a n i n g f u l . I n a c c u r a t e or i n c o m p l e t e entries, without just cause, diminish the reliability of t h e record. O n c e t h e r e c o r d ' s c r e d i b i l i t y h a s b e e n i m p u g n e d , so h a s t h e r e l i a b i l i t y of t h e MICN. Models for documentation SOAP Method --problem-oriented record S S u b j e c t i v e : The history of the patient: both immediate history and the precipitating events, medications, and reactions. Record things the patient has conveyed. O Objective: What you have found through the assessment, including pertinent positive and negative findings from the primary and secondary survey. A Assessment of the incident as a whole: Not a diagnosis, but rather a general impression of the condition(s) presented. P P l a n of action: Treatment rendered to patient. CHARTE Method - - b r e a k s the run down into logical parts; presents an organized report with full analysis of all available facts. C Chief complaint: Patient's description of incident or problem. H History: The patient's immediate history and any precipitating events; medications. A Assessment: The full primary and secondary assessments. R Rx (Treatment): The treatment that was given before arrival of EMS providers and all that was implemented by them on scene. T Transport: The treatment that was given enroute and the mode of transportation. E Exceptions: The problems that were encountered during the run.
Body Systems Approach--probably most conclusive; but difficultto apply in the field.It is an adaptation of nursing assessments.
MIV Method:--least informative and leaves out vital information. This method presents the incident in a very concise manner. The patient and scene information is noted briefly in logical order such as in mass casualty situations.
Figure 1 Models for EMS documentation. Data from Bevelacqua A. Prehospital documentation: a systematic approach. Englewood Cliffs, New Jersey: Brady, 1992.
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Countersigning A l t h o u g h c o u n t e r s i g n i n g a record d o e s not i m p l y t h a t you h a n d l e d the call or wrote the record, it does verify t h a t you r e v i e w e d the entry(ies), a p p r o v e d t h e s t a t e m e n t s noted, or care given, thereby strengthening the assumption that the record is accurate. If you are a p r e c e p t o r or are r e q u i r e d to c o u n t e r s i g n a n o t h e r ' s d o c u m e n t a t i o n , r e v i e w t h e record thoroughly. M a k e sure it is comp l e t e a n d accurate. If you rely on t h e o r i g i n a t o r ' s c o m p e t e n c y a n d sign hurriedly, or c a r e l e s s l y overlook s u b s t a n d a r d care, you could share l i a b i l i t y for any damages. Complete Ideally, t h e c o m m u n i c a t i o n s log s h o u l d s t a n d alone as a chronologic r e c o r d i n g of all out-of-hospital events. Unfortunately, MICNs rarely h a v e t i m e to note e v e r y t h i n g r e p o r t e d from the field, a n d some areas on the log m a y be left s u s p i c i o u s l y e m p t y . To the b e s t of y o u r ability, avoid l e a v i n g b l a n k s p a c e s on the record u n l e s s local protocols clearly allow for c h a r t i n g b y exception. It is helpful if b o x e s are p r e s e n t t h a t allow quick c h e c k m a r k s n o t i n g e i t h e r " w i t h i n n o r m a l l i m i t s " or other locally c u s t o m i z e d n o t a t i o n s s u g g e s t i n g a p a t h o l o g i c c o n d i t i o n (nausea, v o m i t i n g , cough, etc.) E q u a l l y helpful are check b o x e s for r o u t i n e a s s e s s m e n t s , such as quantification of pain, p u p i l size a n d reactivity, b r e a t h sounds, skin color, t e m p e r a t u r e , moisture, level of consciousness, G l a s g o w C o m a Scale scores a n d t r a u m a scores. F o r m s c o n s t r u c t e d to facilitate quick n o t a t i o n s of care r e n d e r e d in t h e field, d e s t i n a t i o n , a n d estim a t e d t i m e of arrival are also b e n e f i c i a l p r o v i d e d local protocols define t h e a p p l i c a b l e s t a n d a r d s of practice. It will be a r g u e d t h a t if records are e r r o n e o u s in one r e s p e c t t h a t t h e y also are faulty in others. If the record does not s u b s t a n t i a t e your claim, it will be difficult to convince a jury t h a t your m e m o r y of dist a n t e v e n t s is superior to your w r i t t e n n o t a t i o n s r e n d e r e d at t h e time. Do not try to cover up an embarrassing fact It is a l w a y s p r e f e r a b l e to disclose d a m a g i n g or e m b a r r a s s i n g information, such as a m e d i c a t i o n d o s a g e error. The fact t h a t an error w a s m a d e d o e s not a u t o m a t i c a l l y i m p l y n e g l i g e n c e . The p a t i e n t m u s t suffer d a m a g e s , a n d t h e p r o x i m a t e c a u s e of the d a m a g e s m u s t be p r o v e n before an a l l e g a t i o n of n e g l i g e n c e is generally s u s t a i n e d . Timely The MICN s h o u l d d o c u m e n t as m u c h as p o s s i b l e d u r i n g t h e run. If this c a n n o t be d o n e contempora~ neously, jot d o w n s h o r t h a n d notes so t h a t d e t a i l s
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r e m a i n fresh until you can finish t h e record. All vital signs, r h y t h m i n t e r p r e t a t i o n s , a s s e s s m e n t s , a n d out-of-hospital i n t e r v e n t i o n s s h o u l d b e t i m e d u n l e s s local protocols i n d i c a t e otherwise. C o m m o n errors on t e l e m e t r y logs i n c l u d e e s t i m a t i n g t i m e s for the a b o v e - m e n t i o n e d d a t a sets. MICNs q u e s t i o n w h e t h e r t h e y s h o u l d note t h e t i m e t h e report w a s c a l l e d in or w h e n the EMTs m a y h a v e o b t a i n e d t h e information. Local s t a n d a r d s s h o u l d s t i p u l a t e w h i c h t i m e s h o u l d b e recorded. It is confusing if the preh o s p i t a l run s h e e t lists different t i m e s a n d interv e n t i o n s t h a n t h e t e l e m e t r y log. Who s h o u l d be believed? One solution is to h a v e a box t h a t i n d i c a t e s "prior to c a l l i n g " (PTC). This m e t h o d allows an MICN to note those a s s e s s m e n t s or i n t e r v e n t i o n s t h a t w e r e c o m p l e t e d b y EMTs before e s t a b l i s h i n g
H a v e a b o x that i n d i c a t e s "prior to c a l l i n g " (PTC). This m e t h o d a l l o w s a n MICN to n o t e t h o s e a s s e s s m e n t s or interventions that were completed by EMTs before establishing communication.
c o m m u n i c a t i o n , at t i m e s n o t e d b y t h e m on their run sheet. It also h e l p s to d i s t i n g u i s h the a s p e c t s of a call t h a t w e r e carried out by EMTs u n d e r s t a n d i n g m e d i c a l orders v e r s u s the d i r e c t m e d i c a l control of an MICN. Therefore t i m e s on t h e n u r s e ' s log u s u a l l y i n d i c a t e e i t h e r the t i m e he or she w a s first a w a r e of field d a t a or t h e point at w h i c h further orders w e r e initiated. An a t t o r n e y m a y u n d e r m i n e t h e reliability a n d a c c u r a c y of your m e d i c a l control b y q u e s t i o n i n g the t i m e l i n e s s of your orders. T r a n s c r i p t s from a r e c e n t d e p o s i t i o n i l l u s t r a t e this point. The following d i a l o g reflects t h e q u e s t i o n i n g of a t e l e m e t r y nurse b y the plaintiff's a t t o r n e y w i t h r e s p e c t to her h a n d l i n g of an out-of-hospital b r e e c h birth: 0 . "Okay. This w a s a b r e e c h birth?" A . " T h a t ' s correct." O. " A n d you k n e w that at the very start of the con versa tion ?" A . " T h a t ' s correct."
Ma~tera/JOURNALOF EMERGENCY NURSING
Oo " W h y did you n o t tell the p a r a m e d i c s to imm e d i a t e l y g e t that b a b y to the hospital?" A , "Birth w a s i m m i n e n t . " 0 . "Birth w a s i m m i n e n t ? " A , "Birth w a s in progression. A n d you don't imm e d i a t e l y bring a b a b y that is b e i n g delivered right to the hospital. You proceed and try to deliver that baby." More q u e s t i o n s followed: O, "Do you k n o w that a h a f f hour w e n t b y from the time the p a r a m e d i c s arrived to the time of arrivai at the hospital?" A , "I don't k n o w . " 0 , "You don't k n o w that or do you k n o w that?" A . "The only w a y I k n o w that is b y the p a r a m e d i c run s h e e t . " More q u e s t i o n s . . . . it is e s t a b l i s h e d t h a t t h e n u r s e h a d s p o k e n b y t e l e p h o n e w i t h an o b s t e t r i c i a n to s e e k a d d i t i o n a l d i r e c t i o n a n d t h a t an e m e r g e n c y p h y s i c i a n w a s at her side. O, " H o w long did your conversation with Dr. X take total?" A . "'I den't h a v e a n y idea." O. "You said you were g e t t i n g directions from Dr. Y. Apparently, you were also g e t t i n g directions from Dr. X?" A , "Just from the one p h o n e conversation." Q. "Which c o n s i s t e d of h o w m a n y q u e s t i o n s a s k e d of Dr. X ? " A . "I don't r e m e m b e r h o w m a n y q u e s t i o n s there actually w e r e . " 0 . " A n d the course you took in regard to b e c o m i n g certified as an e m e r g e n c y room nurse, part of which pertained to birth deliveries. Did you r e c e i v e instruction that in the e v e n t of a b r e e c h delivery out in the field that if there w a s time to g e t the m o t h e r to the hospital s h e should b e transported q u i c k l y to the hospital?" 0 , "You g a v e a n u m b e r of directions in regard to the birth, all of which took time, a p p r o x i m a t e l y h a f t an hour. Can you give m e a reason w h y you didn't insist on those p a r a m e d i c s covering those 2 to 3 m i l e s to the hospital with that m o t h e r and that partially delivered b a b y ? " As you can see, e x a m i n a t i o n u n d e r o a t h in a d e p o s i t i o n m a y b e a g o n i z i n g a n d ask far more t h a n c a s u a l notes m i g h t record. This nurse d i d a s u p e r b job in d i r e c t i n g this difficult run, b u t the a t t a c k on her a b i l i t y a n d c r e d i b i l i t y w a s scathing. The MICN m u s t be as specific as p o s s i b l e in verbal d i r e c t i o n s a n d in d o c u m e n t i n g orders to h e l p aid later recollection of e v e n t s - - t h e d i r e c t i o n s a n d orders s h o u l d b e t i m e d w h e n e v e r possible.
L e g i b l e h a n d w r i t i n g s h o u l d b e a d d e d to t h e criteria for good charting. There s h o u l d be no d o u b t a b o u t w h a t is written. A p a r a m e d i c once told me t h a t he m a k e s his s i g n a t u r e i l l e g i b l e so no one could ever prove he w a s on a call. Such m a g i c a l thinkingr The chart reflects your professional c o m p e t e n c y and, in m a n y ways, your p e r s o n a l style a n d values. M i s s p e l l e d words, s c r a w l e d h a n d w r i t i n g , incorrectly u s e d m e d i c a l t e r m i n o l o g y ( c h a r t i n g CheyneStokes v e n t i l a t i o n s w h e n t h e y w e r e a c t u a l l y ataxic), a n d u s i n g n o n s t a n d a r d a b b r e v i a t i o n s are c h a r t i n g n i g h t m a r e s t h a t m a y later h a u n t you. If you c a n n o t r e a d your own report, the jury m a y not be w i l l i n g to b e l i e v e your v e r b a l testimony. In a close decision, a jury m a y a s s u m e t h a t s l o p p y c h a r t i n g i n d i c a t e s s l o p p y care.
Minimum communication log documentation The m i n i m u m d a t a r e q u i r e d for out-of-hospital log d o c u m e n t a t i o n i n c l u d e the following: 9 Call d a t e a n d time 9 Identification of the EMS a g e n c y / v e h i c l e 9 P a t i e n t identification: age, gender, weight, initials 9 P e r t i n e n t h i s t o r y of p r e s e n t i l l n e s s / i n j u r y , r e l e v a n t p a s t m e d i c a l history 9 Chief a n d a s s o c i a t e d complaints; quantify p a i n / d i s t r e s s on a scale of 0 to 10 9 Patient a s s e s s m e n t findings: chronologic notation of scene survey, physical assessments, vital signs, a n d all other relevant observations 9 Results of d i a g n o s t i c t e s t s such as capillary glucose r e a d i n g s a n d EKG r h y t h m 9 Care r e n d e r e d before arrival 9 A n y h o s p i t a l - g e n e r a t e d orders 9 Clinical o b s e r v a t i o n s i n c l u d i n g r e s p o n s e s to i n t e r v e n t i o n s , w h i c h are as i m p o r t a n t as the i n t e r v e n t i o n itself 9 Final d i s p o s i t i o n a n d e s t i m a t e d time of arrival 9 For t r a u m a p a t i e n t s : m e c h a n i s m s of injury, G l a s g o w C o m a Scale score, a n d t r a u m a scores; r e s c u e / e x t r i c a t i o n information 9 F a c t s s u p p o r t i n g the i n t e n s i t y of t h e p a t i e n t evaluation and treatment, including thought p r o c e s s e s a n d t h e c o m p l e x i t y of m e d i c a l decision m a k i n g 9 L e g i b l e s i g n a t u r e ( s ) a n d n a m e s of m e d i c a l control p e r s o n n e l 9 C o m m u n i c a t i o n method: t e l e m e t r y (UHF) radio, VHF radio, phone, or cellular phone; q u a l i t y / c l a r i t y of t r a n s m i s s i o n s 9 Notation of other a g e n c i e s on s c e n e (i.e., police)
June 199.~
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JOURNAL OF EMERGENCY NURSINQ/Mattera
Refer to local protocols for the m i n i m u m d a t a s e t s in your area.
Amending a record R e p o r t s w i t h o b v i o u s c h a n g e s b u t w i t h o u t approp r i a t e n o t a t i o n s are suspect. A n y a l t e r a t i o n s s h o u l d b e a c c o m p a n i e d b y an e x p l a n a t i o n a n d t h e d a t e of t h e c h a n g e . The p r e v i o u s entry s h o u l d still be r e a d a b l e . Do not d i s c a r d a n y original records or recopy t h e log. Do not b a c k d a t e a n y records. If it app e a r s t h a t you h a v e a l t e r e d or o t h e r w i s e t a m p e r e d w i t h a notation, it r a i s e s q u e s t i o n s a b o u t t h e n a t u r e of t h e r e v i s e d entry, t h e l o g ' s accuracy, a n d your honesty. To a p p r o p r i a t e l y correct an error in a report, d r a w a s t r a i g h t line t h r o u g h t h e m i s t a k e so t h a t it r e m a i n s legible. Write "incorrect entry," "disreg a r d , " or "error" a b o v e or b e s i d e the original entry, sign your n a m e or initials, a n d d a t e t h e c h a n g e . At t h e n e x t a v a i l a b l e spot in t h e record, a n e w note, d a t e d a n d s i g n e d , s h o u l d be w r i t t e n to e x p l a i n the n e e d for t h e correction. If it is n e c e s s a r y to record more information, a s u p p l e m e n t a l r e p o r t - - c l e a r l y i n d i c a t e d as a late e n t r y - - s h o u l d be recorded. It s h o u l d b e d a t e d , c o n t a i n t h e r a t i o n a l e for t h e a d d i tions, a n d t h e s i g n a t u r e of t h e p e r s o n w h o m a d e them. Never a t t e m p t to d e l e t e information or alter exi s t i n g d o c u m e n t s after l e g a l action h a s b e e n initiated. Falsification of r e c o r d s is e v i d e n c e of "cons c i o u s n e s s of n e g l i g e n c e . " If s u b p o e n a is i s s u e d for use of t h e records for information, tl~e r e q u e s t e d d o c u m e n t s s h o u l d be r e v i e w e d b y t h e h o s p i t a l ' s att o r n e y to d e t e r m i n e w h e t h e r a s u p p l e m e n t a l report s h o u l d be created.
Checklist for d o c u m e n t a t i o n As you q u i c k l y scan your l o g , ask yourself the following questions: 9 Does t h e record c o n t a i n all t h e information n e e d e d b y yourself a n d others w h o m a y rely on t h e record? Like a story, a report n e e d s a logical b e g i n n i n g , m i d d l e , a n d conclusion. 9 Does your record a d e q u a t e l y s t a t e all of the E M T ' s r e p o r t e d o b s e r v a t i o n s a b o u t t h e patient? Are t i m e s l i s t e d n e x t to all o b s e r v a t i o n s or i n t e r v e n t i o n s ? 9 Does t h e record list all out-of-hospital treatm e n t ( s ) g i v e n a n d the p a t i e n t ' s r e s p o n s e s ? 9 Does t h e t r e a t m e n t fit t h e r e p o r t e d observations a b o u t t h e p a t i e n t w i t h i n the a e g i s of local s t a n d i n g m e d i c a l orders?
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9 Is t h e record c o m p l e t e e n o u g h so t h a t you could m e n t a l l y r e c o n s t r u c t t h e e n t i r e call a n d d e f e n d your a c t i o n s at a later d a t e if you w e r e r e q u i r e d to do so? 9 Do your records conform to t h e d e t a i l dem a n d e d by your local s t a n d a r d s of practice (e.g., t i m i n g of vital signs, c o m p l e t e n e s s of assessments)? 9 Does t h e record i n c l u d e a l e g i b l e signature w i t h c r e d e n t i a l s a u t h e n t i c a t i n g the record?
Documentation tips 9 D o c u m e n t in b l a c k ink. Black is g e n e r a l l y u s e d to d e n o t e a legal record a n d p r o d u c e s c o p i e s t h a t are more e a s i l y r e a d a b l e , w h i c h is often n e c e s s a r y if t h e c h a r t is going to be microfilmed. Further, some of t h e n e w c o m p u t e r s c a n n e r s will not r e a d colored inks. 9 Press hard if the record is p r i n t e d on mult i p a g e c a r b o n l e s s p a p e r so all copies all legible. 9 D o c u m e n t s i g n s a n d s y m p t o m s as r e p o r t e d b y EMTs. Use a p a t i e n t ' s o w n w o r d s w h e n ever possible. E n c a s e q u o t e s in q u o t a t i o n marks. 9 D o c u m e n t a n y i n t e r v e n t i o n s i n i t i a t e d by EMTs or o r d e r e d b y t h e b a s e station a n d the p a t i e n t ' s r e s p o n s e s to t h e i n t e r v e n t i o n if t h a t information is k n o w n before the a m b u l a n c e arrives at t h e hospital. 9 D o c u m e n t e n o u g h i n f o r m a t i o n to d r a w logical conclusions a b o u t t h e a p p r o p r i a t e n e s s of out-of-hospital care. 9 The p e r s o n s c r e a t i n g t h e d o c u m e n t m u s t be i d e n t i f i e d b y n a m e a n d c r e d e n t i a l s , w i t h legible signature. Consult local policy w i t h reg a r d to t h e n e c e s s i t y of p r e c e p t o r or p h y s i c i a n co-signers.
Summary All MICNs m u s t m a i n t a i n a h i g h d e g r e e of commitment, b o t h to their c o m p e t e n c y to p r o v i d e quality m e d i c a l control for out-of-hospital calls a n d the p r a c t i c e of quality d o c u m e n t a t i o n . G e n e r a t i n g a leg a l l y d e f e n s i b l e c o m m u n i c a t i o n s log is a skill req u i r i n g more a t t e n t i o n to d e t a i l t h a n it often receives. MICNs n e e d to a p p r e c i a t e t h a t a legal record is b e i n g c r e a t e d t h a t m a y b e s u b p o e n a e d in t h e s a m e m a n n e r as ED charts. The b e s t m a l p r a c t i c e i n s u r a n c e a v a i l a b l e is an e m e r g e n c y record prep a r e d so t h a t it is l e g a l l y c a p a b l e of s t a n d i n g on its o w n merit.
Mattera/JOURNAL OF EMERGENCY NURSING Suggested readings Bergerson S. Charting with a jury in mind. Nurs Life 1982;July-Aug:30-3. Bergerson S. More about charting with a jury in mind. Nursing 88 1988;April:51-6. Bevelacqua A. Prehospital documentation: a systematic approach. Englewood Cliffs, New Jersey: Brady, 1992. Fosarelli P, Baker MD. What you don't record can hurt you: documentation in the emergency department. Pediatric Emergency Care 1985; 1:223-7. George J, Quattrone M, eds. Documentation: the most important tool. Emergency Physician Legal Bulletin 17(1):1-5. George J, Quattrone M, eds. The emergency department medical record. 18(2):1-7. Lampe B. 10 steps to writing better run reports. Emergency 1991;Oct:37-41.
Mandell M. Charting: how it can keep you o u t of court. Nurs Life 1987;Sept-Oct:46-8. Mourafetis D. Principles of medical record documentation. Unpublished hospital inservice handout. Arlington Heights, Northwest Community Hospital. Murphy J, Beglinger J, Johnson B. Charting by exception: meeting the challenge of cost containment. Nurs Mana g e m e n t 1988;19:56-72. Nagorka F. Documentation, the only protection. Lecture outline 1992. Schaller J. Documentation of nursing care. N u t s Spectrum 1991;Aug 5:17. Southard P. Trauma care documentation: a comprehensive guide. J EMERG NURS 1989;15:393-8. Tammelleo AD. Ed. Rx: avoid "speculation" and "admissions" in charting. Regan Report on Nursing Law 1990; 30:2.
1 l t h o u g h t h e r e h a d b e e n a s l o w d o w n in t h e form a t i o n of n e w air m e d i c a l p r o g r a m s d u r i n g t h e p a s t s e v e r a l y e a r s , r e c e n t l y t h e r e h a s b e e n a flurry of a c t i v i t y (at l e a s t in t h e N o r t h e a s t ) a s h o s p i t a l s - especially those hospitals that are regional referral h o s p i t a l s in r u r a l a r e a s - - c o n s i d e r s t a r t i n g p r o g r a m s . T h i s s e r i e s of a r t i c l e s is d e s i g n e d to a s s i s t h o s p i t a l s t h a t a r e c o n t e m p l a t i n g a n e w air m e d i c a l p r o g r a m .
A
Needs assessment Before a n y n e w p r o g r a m s t a r t - u p , a n e e d s a s s e s s m e n t s h o u l d b e c o n d u c t e d to d e t e r m i n e t h e a c t u a l n e e d for a p r o g r a m in y o u r r e g i o n . T h i s a s s e s s m e n t s h o u l d i n c l u d e a p r o j e c t i o n of t h e n u m b e r s a n d t y p e s of p a t i e n t s w h o w o u l d b e t r a n s p o r t e d b y air. Gather data about patients previously transported b y g r o u n d units, t h e c a t e g o r y of t h o s e p a t i e n t s (cardiac, t r a u m a , p e d i a t r i c , etc. ), t h e p r e v i o u s t r a n s p o r t t i m e s b y g r o u n d , t h e n u m b e r s of i n s t i t u t i o n s / a g e n -
c i e s t h a t w o u l d u s e y o u r service, a n d t h e p r o b l e m s and patient complications associated with lengthy transport times that could be greatly reduced by a m o r e r a p i d m o d e of t r a n s p o r t a t i o n . Be s u r e to include the problems faced by a community when its o n l y a m b u l a n c e is d i s p a t c h e d for a l e n g t h y p a t i e n t t r a n s p o r t to a t e r t i a r y c e n t e r m a n y m i l e s a w a y a n d t h e d i f f i c u l t y t h e y m a y e n c o u n t e r in findi n g a d v a n c e d life s u p p o r t p e r s o n n e l for t h e t r a n s port. Your d a t a s h o u l d a l s o i n c l u d e t h e e s t i m a t e d n u m b e r of d a y s t h a t y o u r p r o g r a m w o u l d b e una v a i l a b l e b e c a u s e of w e a t h e r a n d o t h e r factors. It s h o u l d i n c l u d e a n a n a l y s i s of t h e r a n g e a n d o v e r l a p t h a t w o u l d o c c u r w i t h o t h e r p r o g r a m s in y o u r For reprints~ write Susan Budassi Sheehy, RN, MSN, CEN, FAAN, 163 Lyme Rd, Hanover, NH 03756. J EMERONURS 1995;21:237-9 Copyright 9 1995 by the Emergency Nurses Association. 0099-1767/95 $3.00 + 0 18/62/64127
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