Early EMS Documentation Formats
One of the first EMS documentation formats was the CHART (chief complaint, history, assessment, Rx [prescription], treatment) method. Rather quickly, Paramedics realized that CHART lacked some needed fields, such as an evaluation of the interventions. CHART was modified to become CHARTIE, adding I for intervention and E for evaluation to the previous information.
Another documentation format that was in common usage is NAP (narrative, assessment, plan of treatment). NAP is a short documentation format that is particularly well-adapted for first responder use. Narrative, the N in NAP, is a written description of the patient’s complaints, current history, and any physical findings such as vital signs, which is written like a story. Assessment, the A in NAP, is typically complaint driven (e.g., shortness of breath). The plan of treatment, the P in NAP, includes disposition, or to whom the patient was turned over.
CHEATED Format
To help meet the Paramedic’s needs for a more complete charting format, Valerie Conrad, EMS QI Coordinator in Traverse City, Michigan, developed an EMS-specific, user-friendly documentation method using the mnemonic CHEATED. The elements of CHEATED (chief concern/complaint, history, examination, assessment, treatment, evaluation, disposition) contain all of the additional fields needed by Paramedics and is inclusive of the SOAP notes previously used. This documentation method is a representation of one effective means of documenting an EMS event.
Chief Concern
The C in CHEATED, chief complaint (CC) or chief concern, is usually the reason that the patient called for EMS. If possible, the chief complaint should be stated in the patient’s own words and placed within quotation marks.
If the patient is unable to speak, then the reason the patient is unable to speak (e.g., "unconscious") should be noted. The caller’s words should then be noted. These are the words usually transmitted to the Paramedic by the dispatcher.
History
The H in CHEATED, history, contains the subjective information provided by he patient, the patient’s family, and/or bystanders. The subjective information provided is called the patient’s symptoms. The patient’s history consists of an explanation of the symptoms (i.e., history of present illness) and the patient’s past medical history.
History of Present Illness
The history of present illness (HPI) is a chronological description of the development of the patient’s present illness, starting with the patient’s chief complaint. If the patient is nonconversational (e.g., because the patient is unconscious), then family and/or bystander comments should be documented. Elements of an HPI typically include location, quality, severity, duration, timing, context, modifying factors, and any associated signs or symptoms of the illness.
The Paramedic’s intent when gathering a history is to develop a symptom pattern. These symptom patterns (i.e., the list of symptoms) are then compared to the Paramedic’s knowledge of other diseases, disorders, and syndromes. When the current symptom pattern matches a symptom pattern for one of these diseases, disorders, or syndromes, then a diagnosis can be made.
The mnemonic OPQRST (onset, provocation, quality of pain, radiation, severity, timing) is commonly used by Paramedics to help develop a symptom pattern (Table 19-2).11 For example, the S in the OPQRST stands for severity. Using the anesthesiologists’ pain scale, the patient is asked to rate the pain from 0, being no pain, to 10, being the worst pain the patient ever experienced. This line of questioning helps to establish the severity of the patient’s pain as well as establish a baseline to gauge the effectiveness of pain relief.
While a patient history can be endless, the Paramedic focuses on those questions that will illuminate the cause of the patient’s problem. It is helpful to have a more structured series of questions for a given problem.
Many EMS agencies have adopted the federal Evaluation and Management Documentation Guidelines created by the Health Care Finance Administration (HCFA), now called the Center for Medicare and Medicaid Services (CMS), and the American Medical Association (AMA). Standardized histories permit the Paramedic to identify diseases, disorders, and syndromes, vis-a-vis, through symptom pattern recognition, and document the medical necessity of the therapeutic services provided to the patient.
With the standardized history in hand, the Paramedic is now able to establish a diagnosis of the disease, disorder, or syndrome using the International Classification of Diseases (ICD-10) coding system.
Table 19-2 OPQRST Mnemonic
|
O |
Onset, the beginning of the symptoms |
|
P |
Provocation, what started or intensified the symptoms |
|
Q |
Quality of the pain |
|
R |
Radiation (Does the pain migrate to another body part?) |
|
S |
Severity, the intensity of the pain |
|
T |
Timing (Do the symptoms wax and wane?) |
The ICD-10 is the latest edition of the international diagnostic classification system that first started in 1893 as the International List of Causes of Death. Since that time, the ICD coding system has evolved and become the standard for the description and classification of diseases.
With the diagnosis made, physicians and administrators can group patient populations with the same or similar diagnosis into diagnosis-related groups (DRG). The original purpose of a DRG was to group patients who used similar resources together for reimbursement from Medicare. These DRG assignments are based on the ICD diagnosis. Currently the DRG, version 25, also takes into account procedures performed as well as the presence of significant comorbidities. In the case of EMS, a patient transport might be reimbursed for respiratory failure, as a DRG, if the patient was intubated. The patient may also be reimbursed for obesity, if the patient had that comorbidity.
For a high-priority patient, the Paramedic would obtain answers to a minimum of three elements among those listed. Elements of a history are listed according to body systems in the guidelines.
For a low-priority patient, the Paramedic would obtain a more detailed history that contains a minimum of six of the elements listed as well as some past medical history, and/or family and social history.
These minimum standards are used for all patients. The Paramedic’s problem-focused history may elect, based on patient condition and clinical judgment, to expand on the history in order to more completely understand the patient’s condition.
STREET SMART
Special notation should also be made if the patient threatens suicide. If possible, the patient’s exact words and the context in which they were said should be noted. It may be the only utterance the patient makes about suicide.
Many Paramedics also document any constitutional symptoms noted. Constitutional symptoms are those general systemic reactions to illness that include fevers, unexplained weight loss, night sweats, chills, headaches, nausea, and vomiting. Constitutional symptoms can indicate that the patient may be infected and the Paramedic should reconsider the choice of personal protective equipment (PPE).
The HPI typically ends with the patient’s pertinent negatives. Pertinent negatives are those symptoms which, if present, could indicate a more serious underlying problem. There could potentially be a large number of pertinent negatives, but Paramedics tend to limit the pertinent negatives specifically to those symptoms that imply pathology in a major organ system.
Starting in a head-to-toe progression, the traditional pertinent negatives are loss of consciousness, chest pain, shortness of breath, and abdominal pain. Other EMS systems may add other pertinent negatives as needed. These four pertinent negatives are ominous if, instead, they are positive. These conditions typically require advanced life support measures.
Past Medical History
Once the HPI is complete, the Paramedic would proceed to document the past medical history (PMH). To aid with documentation of the PMH, the Paramedic often uses the mnemonic AMPLE (allergies, medications, past medical history, last meal, events).
The first element (A) of AMPLE is the patient’s allergies, to both prescription and over-the-counter medications. If the patient has no allergies to drugs, then the acronym NKDA (no known drug allergies) is often used. If the patient has an allergy to a medication, and time permits, it may be helpful to get a history of the reaction to determine if it is a true allergy or an unpleasant side effect of the medication.
The next element (the M in AMPLE) stands for medications. The Paramedic should list all medications—including prescription, over-the-counter, botanicals, and illicit drugs—by name, dose, and frequency, if possible. It is appropriate for the Paramedic to use standard prescription shorthand to list the frequency (e.g., QD for once-a-day). These Latin terms are listed in the medical terminology topic.
The next item (the P in AMPLE) stands for past medical history and should include the primary diseases recognized in each major body system (Table 19-3). Again, progressing in a head-to-toe fashion, a minimal past medical history would include questions about strokes and seizures (neurological), heart attack and hypertension (cardiovascular), asthma and chronic obstructive pulmonary diseases (COPD) (respiratory), diabetes (endocrine), and cancers (Ca). If the patient has a preexisting diagnosis for a disease, then that should also be listed.
Review of Systems
A more complete past medical history uses a systems review approach to history gathering. Using a head-to-toe approach, the following systems review represents a more complete history gathering. The systems review can be used as a part of a comprehensive examination, or portions can be used to obtain a more complete focused examination.
Table 19-3 Example of a Minimal Past Medical History
|
• |
Stroke |
|
• |
Seizure |
|
• |
Heart attack |
|
• |
Hypertension |
|
• |
COPD |
|
• |
Asthma |
|
• |
Diabetes |
|
• |
Cancer |
Starting at the head, the patient should be asked if he has ever had a stroke, seizure, or traumatic brain injury (TBI). If the patient answers affirmatively to any of these stated conditions, then the Paramedic would use that opportunity to launch into a more extensive line of questioning. For example, if the patient admits to a history of seizures, then the Paramedic could inquire about the frequency of seizures, the date/time of the last seizure, what medications the patient is taking for the seizure condition, as well as compliance with those medications.
Proceeding to the cardiovascular system, the patient should be asked if he ever had angina (chest pain) or a diagnosis of acute myocardial infarction (AMI). If the patient answers yes, then the Paramedic might inquire which portion of the heart was affected. Next, the Paramedic would inquire about angioplasty, including the results and/or a coronary artery bypass graft (CABG). Some patients are so well educated about their condition that they can tell the Paramedic which vessel was involved, the percentage of blockage, and even their last ejection fraction.
A review of the respiratory system starts with documentation of any lung disease and often includes smoking history, listed in packs/years, and a diagnosis of emphysema.
The Paramedic should document any abdominal surgeries, including appendectomy, history of small bowel obstruction, and the presence of an abdominal aortic aneurysm, repaired or not repaired (Figure 19-4).
Proceeding to the genitourinary system, the Paramedic should document any history of sexually transmitted diseases. If the patient is a female, then a reproductive history—including the number of pregnancies and delivery of newborns—should be documented. A history of kidney stones may also explain flank/groin pain and should be documented.
If the patient has an extremity injury, then past medical history of injuries to the extremities, as well as the musculo-skeletal system, should be documented. The history should include documentation of prior sprains, strains, and fractures, especially those that required surgical correction. Often Paramedics also take and document a pain history at this point, especially in regard to the prior use of morphine for similar injuries, in anticipation of orders for analgesia.
Figure 19-4 A Paramedic taking a history.
The Paramedic should document any endocrine disorders including diabetes, thyroid disorders, and thyroid surgeries. Similarly, any hematological disorders—such as leukemia, infections, blood transfusions, and overseas travel—should be documented.
If the patient has a behavioral disorder, then the Paramedic should document previous psychiatric admissions, any psychotropic medications, and use of alcohol or illicit drugs.
While the review of systems can be exhaustive, the intent is to discover preexisting medical conditions and then explore the medical treatments received for those conditions which might impact on current prehospital care. The previously listed questions in the review of systems merely cites some representative questions that could be used. More questions may be appropriate (Table 19-4).
The L in AMPLE has various interpretations. It typically stands for last meal. This is an important question if the patient may be destined for the operating room. Surgeons prefer patients who have not eaten prior to surgery (N.P.O.), thereby lowering the risk of aspiration. Some Paramedics also use the L to indicate last bowel movement (if the chief concern is abdominal pain) or last menses (if the patient could have a gynecological problem). Some Paramedics may use L to mean last time a medication was taken when the patient has a known history of epilepsy or diabetes.
The final element in AMPLE (E) refers to events and generally is aimed at previous events of the same or similar nature and/or other previous encounters with EMS.
Examination
The physical examination of the patient, the E in CHEATED, often starts with the position and condition in which the patient was found. For example, if the Paramedic finds the patient with shortness of breath in a tripod position, the Paramedic would note that as part of his general impression and document the same.
This type of "from the doorway" assessment is referred to as a constitutional examination. The constitutional examination assesses the patient’s general appearance. Examples of the two extremes of appearance is the patient in extremis, or having great difficulty, and the patient in no apparent distress (NAD) (i.e., not appearing to be having difficulty). This "sick-not sick" impression can help the Paramedic establish the tempo of the call.
Table 19-4 Standard Review of Systems
|
• |
Neurological |
|
• |
Cardiovascular |
|
• |
Pulmonary |
|
• |
Gastrointestinal |
|
• |
Endocrine |
|
• |
Genitourinary |
|
• |
Integumentary |
|
• |
Musculoskelal |
The constitutional examination may also contain objective observations about the patient’s physical development such as "emaciated" or "obese." These descriptions speak to the patient’s body habitus. For example, the morbidly obese patient typically has a list of medical conditions, such as heart failure and diabetes, associated with being obese. These descriptions of the patient are not slanderous or insulting, but are objective statements which are intended to make an inference about the patient’s health.
Similarly, any overt deformities as well as personal grooming habits relate to the patient’s health or the patient’s ability to maintain health. The first sign of Alzheimer’s disease, for example, may be the patient’s inability to perform the activities of daily living, including personal grooming.
The Paramedic would then proceed to document the findings of the initial assessment, including the treatment of any life-threatening injury.
Next, the patient’s vital signs are recorded. For blood pressure, it should be noted whether it was taken while the patient was supine, seated, or standing. For pulse, regularity (as well as rate, respirations, and temperature) should be recorded.
If the patient was high priority, then the Paramedic would document the problem-focused examination findings. The problem-focused examination, sometimes referred to as a vectored examination, is limited to the affected body area or organ system reflected in the chief complaint. The various body systems examined in a problem-focused examination include, from head-to-toe, the neurological system, the cardiovascular system, the respiratory system, the gastrointestinal system, the musculoskeletal system, and the psychiatric exam.
For example, a problem-focused physical examination for a patient with a complaint of substernal chest pain would include the cardiovascular system. Taking a look, listen, and feel approach to physical examination, the Paramedic would document the presence or absence of jugular venous disten-tion and pedal edema. The auscultatory findings, including bilateral blood pressures and heart sounds, would be documented. Finally, findings assessed by palpation, such as pedal pulses and the location of the point of maximal intensity (PMI), might be documented.
It should be noted that any documentation of the abnormal without further elaboration is insufficient. The assumption is that the patient has normal findings unless otherwise noted.
If the patient is a low-priority patient, then a more detailed physical examination would be performed (Figure 19-5). Some Paramedics, especially in trauma cases, prefer a head-to-toe approach to the detailed physical examination, whereas others prefer a body systems approach to the examination.
If an ECG is attached to the documentation, it is important that the Paramedic standardize the notation of interpretation.
Figure 19-5 Paramedic performing a physical examination.
For example, all ECG criteria should be listed (QRS width, etc.) prior to noting an identification of the ECG rhythm. Many Paramedics will use a broad label, such as a narrow-complex tachycardia, and then note a presumptive interpretation, such as paroxysmal atrial tachycardia.
Assessment
While it is important for the Paramedic to accurately and completely describe the patient’s condition, in order to arrive at a paramedical diagnosis, it is almost as important for the Paramedic to consider what is not seen. Documentation showing consideration of other possible etiologies demonstrates that the Paramedic has an open mind to other potential diagnoses and has considered them and then rejected them. This "head’s up" attitude helps prevent the Paramedic from focusing too narrowly based on an assumption, without considering other possibilities. For example, the chest pain experienced by a patient could be due to pulmonary embolism secondary to a deep vein thrombus. If the Paramedic were to focus exclusively on a cardiac examination, he might miss the source of the pathology.
Following the discussions of various pathologies in subsequent topics, the "rule out" or differential diagnosis for specific complaints will be discussed.
Paramedical Diagnosis
With the history and physical examination documented, the Paramedic would proceed to document the assessment. The assessment is, partly, a protocol-driven medical decision. Typically, for high-priority patients Paramedics use advanced life support (ALS) protocols, whereas for low-priority patients basic life support (BLS) protocols are used.
The documentation of the protocol-driven field diagnosis asserts and reinforces the Paramedic’s medical control. If direct contact with medical control is made for purposes of consultation and specific orders, then that should be noted as well.
Treatment
The next section of the PCR is the treatment section. All interventions performed, both BLS and ALS, should be noted in the treatment section. If BLS first responders had already initiated patient care, then these treatments should also be noted in the treatment section, with the notation "performed by EMT Jones."
Evaluation
Following every treatment there should be an evaluation of the effectiveness of that treatment, or, at a minimum, a statement about the patient’s ongoing condition. This is the evaluation phase of patient care.
Some have argued that Paramedic care is an unnecessary expense and that the majority of the Paramedic’s treatments are ineffective, at best. Accurate documentation of the effect of prehospital care helps to demonstrate the value of early medical treatments performed by Paramedics.
Disposition
The last section of the CHEATED PCR is disposition. Some Paramedics refer to this as the patient report, a summary of the patient’s condition and the status of treatments in progress when patient care was given over to another Paramedic or healthcare provider. It is imperative that the Paramedic document to whom the patient was turned-over-to (TOT) in order to avoid accusations of patient abandonment.
The disposition should also contain information about the patient’s condition (i.e., changes and improvement), as well as the status of treatments. For example, a Paramedic might document that oxygen was continued, that the IV remained patent, and state the rate of infusion. The Paramedic might also want to document the volume of fluid infused as well as whether blood samples were turned over to the emergency department personnel. Finally, the Paramedic may document if the patient was left in the care of family, friends, or hospital personnel.
STREET SMART
After the patient is transferred from the ambulance gurney to the hospital stretcher, the side rails on the stretcher should be raised unless the patient is attended to by a hospital staff member. "Side rails up times two" is often the final line of documentation on the PCR.
Special Documentation
Several situations are not amenable to standard documentation procedures. These situations require special documentation or special notations, which will be discussed individually in the following section.
Refusal of Medical Assistance Documentation
The CHEATED format works well for documentation of refusal of medical assistance (RMA). Starting with the chief complaint, or chief concern, the Paramedic would document the history and the physical examination to the extent permitted by the patient.
In the assessment section, the Paramedic would address the issue of competence, including noting the patient’s age. If the patient is of age, or is an emancipated minor, then the Paramedic would proceed and document the patient’s mental status.
Any physical or medical conditions that would prohibit the patient from consenting (e.g., intoxication or presumption of stroke) should be documented. Actions taken by the Paramedic to enlist the assistance of family, medical control, or law enforcement officers to convince the patient to seek medical attention should be documented as well.
In the treatment portion of the PCR, all treatments permitted by the patient, including those offered but refused, should be documented.
Instead of completing an evaluation, because treatment is being refused, the E in CHEATED means explanation of outcomes. The Paramedic should document that the patient was advised of foreseeable complications that are reasonably likely to arise, which could seriously jeopardize the patient’s health and bodily functions or result in a serious dysfunction of an organ or body part if medical attention is refused.
The explanation of outcomes documented should include a list of the symptoms for which the patient should reconsider and recall EMS. Also, the encouragement to seek medical attention from a private physician should be noted.
Under the final disposition portion, the Paramedic should document with whom the patient was left and the patient’s ability to summon aid or recontact 9-1-1.
The patient should then be asked to sign the completed PCR. A copy of the PCR should be left with the patient, if possible. Some EMS systems use special documentation forms for refusals of medical care. If the patient is unwilling to sign the PCR, the Paramedic should note the refusal and obtain the names, and signatures, of witnesses.
Hazardous Materials Operations Documentation
Key to hazardous materials operations documentation is an understanding that such documentation may be called into play in lawsuits and disability hearings years after the patient was seen by the Paramedic. Complicating matters, the average hazardous materials technician being assessed by EMS may not have any significant complaints and yet is given an on-scene physical examination as a part of the process of decontamination.
Using the CHEATED format in this venue, the Paramedic should document, under chief complaint, the exact potential chemical exposure, or exposures, if known. Under the history section, the Paramedic should explain the circumstances which caused the exposure.
A standard well-person physical examination, including vital signs, should be documented. Many EMS systems also perform a baseline cardio-thoracic examination for later comparison.
The patient’s assessment and treatment are usually based upon prewritten protocols. The Paramedic should document if the patient’s physiological condition meets or fails to meet those parameters and if treatment is indicated. In some instances, the treatment is limited to what is typically offered in a fire rehabilitation sector.
Finally, the patient’s disposition, such as discharged to rehabilitation, discharged to home, or transported for further evaluation, should be documented.
Documentation of Multiple Casualties
Understandably, Paramedics cannot take the time to perform standard documentation during a mass casualty incident. In those circumstances, the triage tag is the only documentation that will be performed.
At the end of the incident, the Paramedics should complete an event report that details, like the hazardous materials incident report noted previously, the situation and conditions that occurred which led to the mass casualty incident. The event report should be as detailed as possible. The triage tags are then attached to the event report as a part of the permanent record.
In some cases, human error may have contributed to the incident and charges of negligence may be brought against those individuals who are believed to be responsible.15-16 In that situation, the Paramedic may subsequently be called to testify about the conditions on-scene as well as the patient care provided.
Documentation of Pregnancy and Childbirth
Standard EMS documentation is designed to document the condition of an ill or injured person. The pregnant woman is neither ill nor injured. The wellness examination of the pregnant woman focuses on documenting the state of the pregnancy as well as identifying potential complications of childbirth.
Starting with a prenatal questionnaire, the Paramedic should document the answers to the questions about this pregnancy, such as date of last menstrual period (LMP) and/or the expected date of delivery (EDD). The Paramedic should then proceed to ask about inherited risk factors, personal habits (such as smoking or alcohol use), as well as document a systems review of the patient’s health. When the prenatal questionnaire is completed, the Paramedic would document the patient’s pregnancy history, including past difficulties with delivery.
Special Incident Report
Many Paramedics are asked to complete documentation that is not directly related to patient care. These documents, that can be broadly termed special incident reports (SIR), are used for administrative purposes or as a part of a court proceeding.
One special incident report is an exposure report. The exposure report, separate from the patient care report that should be generated for each individual who was seen after exposure, details the circumstances that resulted in the Paramedic being exposed. The intention of an exposure report is to identify the problem and then correct the problem so that another exposure cannot occur. Therefore, names of exposed individuals may not be needed on the report. Under most circumstances, the designated officer (DO) for the agency receives the exposure report and would make recommendations for corrections to prevent problems in the future.
In most states, Paramedics are considered mandatory reporters of child abuse and are required to complete a standardized reporting form. This type of report would be considered a special incident report. Similar forms may also be available for reporting domestic violence or elder abuse.
Legal Proceedings
When a Paramedic has been a witness to a crime, or is a named party to a claim of negligence, the Paramedic may be called upon to provide special documentation.
Some attorneys, or legally authorized persons, may only request that the Paramedic make a legal sworn statement, called an affidavit, about the events surrounding an incident. These statements are voluntary and typically witnessed by a notary public.
A deposition is the testimony of a witness (in this case, a Paramedic) in a setting outside of a court, where attorneys from both parties can interrogate the witness. The sworn testimony given by the witness is recorded by a stenographer. A transcript, a word-for-word account, is then produced for use in the lawsuit and may be submitted into evidence in a court of law. Often Paramedics rely on the PCR or a SIR to refresh recollection or for background information regarding the case.
In some cases, the attorney may elect to have the Paramedic answer questions in a written deposition, in a manner similar to an affidavit.
Conclusion
Documentation is an important aspect of EMS. The quality of patient care, and the Paramedic’s professionalism, is often reflected in the patient care report. The beneficial nature of a patient care report is a function of its ability to communicate the message that the sender (the Paramedic) intended for the receiver (the emergency physician). By learning the correct medical terminology and abbreviations, and reporting thoroughly but concisely while utilizing a charting format consistently, the Paramedic can expect success with her documentation.
key points:
• The first purpose of documentation is to use it as a medical record.
• The patient care report is also used for quality assurance and performance improvement.
• The PCR is also a business record used to bill federal and state governments as well as private insurance.
• The PCR is a legal document used in litigation.
• Documentation standards help to ensure that the standard of care was met.
• Specific protocols should be in place to resolve errors and omissions.
• In an electronic age, safeguards must be in place to ensure patient privacy from unwarranted invasion.
• While many documentation formats exist, Paramedics should choose the one that meets their agency’s needs and provides the most complete documentation of the events that transpired.
• Special events, such as hazardous materials incidents or multiple casualty incidents, require a special incident report.
