"We are what we repeatedly do. Excellence, then, is not an act, but a habit." ~ Aristotle

Thursday, July 7, 2011

Documenting Care

I've recently completed a presentation on patient care documentation, and would like to share a few thoughts about the topic. The idea to put on this presentation was born when a member of an agency I work for asked me if I'd be interested in teaching my charting style. I found the request intriguing, primarily because until that point I'd been chided by my fellow providers for "writing novels" and "milking the overtime" when I get a late call and have to spend time thoroughly charting a call. I can also say that has been the sentiment of some of my past supervisors as well. Let's be honest, the notion that a BLS provider's chart should be short, sweet, and done in 20 minutes is so 1990's.

While its true that BLS providers have a lesser degree of pre-hospital education than Paramedics, over the past several years the level of care expected from BLS providers has increased dramatically. For example, we're now using more medications than ever before, and although the number is still small in comparison with the arsenal carried by ALS providers, and BLS providers are needing to become better clinicians in order to effectively deploy these treatments. It's simply not enough to say "patient exhibiting signs of anaphylaxis, mother reports previous prescription of epi-pen, used same."

A better way of charting that same situation: "Patient's mother reports history of severe allergic reaction to peanuts and child mistakenly took a bite of a peanut butter sandwich. Phyiscal examination revealed patient audibly wheezing upon exhalation, oropharynx & tongue swelling, use of accessory muscles during inhalation, and hives across chest and upper arms. In accordance with regional Standards of Care, administered high-flow oxygen at 15 LPM via non-rebreather mask as well as 0.15mg epinephrine auto-injector via IM into patient's left thigh." This example, as compared to the preceding, shows a provider who's a clinician and not a technician. They use clinical findings to justify care instead of simply documenting "rote" procedures.

In my service area, BLS providers are, generally, the first to arrive on a scene. That being said, they are now the first set of trained eyes to evaluate the situation and have a very important role in providing a portrait of what they find. Let's take the following example: "Arrived on scene to find a two car crash with an SUV on its side and a person trapped inside. Other driver was out of vehicle and walking around."

Compare those two sentences with the following: "Arrived on scene to find a two vehicle collision involving a white Nissan Sentra and a black Toyota Highlander at the intersection of Walk Street and Don't Walk Road. Nissan Sentra was facing westbound in eastbound lane of Walk Street and appeared to have significant front-end damage, including starring of windshield. A middle aged white female was walking near her vehicle while talking on her cell phone and appeared to be bleeding from her forehead.  The Toyota Highlander was resting on its passenger side in the ditch on the northwest corner of the intersection with impact damage to the driver's door as well as crushing damage to the roof. A teenage white male was seated in the driver's seat, seatbelt engaged, and complaining of head, neck, and back pain." Paints a more thorough picture, doesn't it?

Last but not least, proofread your work before submitting it. In the age of electronic records, "spell check" isn't going to catch everything. Case in point: a major electronic charting software spell check feature found the following sentence to be correct: "Patient reports he feel from a latter while working on a ruff. He says that he landed on his back and that his arm hurts. He doesn't remember felling but no's the day, address, and month."

Obviously this was a farcical example, but did you find all the errors? How about this: "Patient reports he fell from a ladder while working on a roof. He says that he landed on his back and that his arm hurts. He doesn't remember falling but knows the day, address, and month." That doesn't take spell check; it takes proofreading.

The take home message is this: a pre-hospital care record is a multi-purpose tool. It is a part of the patient's medical record, it is a legal document, and it paints a picture of what happened between the time you arrived and transfer of care to hospital staff. This means everything, up to and including how you moved the patient to the hospital bed (two-person sheet draw), what you did to ensure his or her safety in the bed (rails up, call button at patient's left hand), and who you provided a transfer of care report to (yes, including the name). The most important part of documenting a chart is that this is YOUR memory of the call as it happened. Will you honestly remember all the details you left out of the narrative if you ever have the misfortune of being called to testify in court?

Until we meet again, be safe.