This chapter include 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; describe the elements of a properly written emergency medical services (EMS) document; describe an effective system for documenting the narrative section of a prehospital patient care report;. | 9/10/2012 1 Chapter 4 Documentation 2 Lesson Importance of Documentation 3 Copyright © 2013 by Jones & Bartlett Learning, LLC, an Ascend Learning Company 1 9/10/2012 Learning 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. 4 Reasons 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 5 Reasons for Written Documentation • Written documentation provides for – Tangible record of incident – Legal record of incident – Professionalism – Medical audit – Quality improvement – Billing, administration – Data collection 6 Copyright © 2013 by Jones & Bartlett Learning, LLC, an Ascend Learning Company 2 9/10/2012 Reasons 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 research 7 Reasons 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 8 Reasons 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 – .
