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.

"Wouldn't it be nice if they...."

Going along with my previous post about finding balance, you need to know when to laugh at yourself. Today my partner said he'd "never seen someone go through emotions as fast as you." What happened?

Well, returning to quarters from a transport the garage door opener flew off the sun visor and landed on the dash. Considering I'm on an expressway at the time, I just leave it there. Upon pulling in front of the garage door, I pull forward, then line the ambulance up and stop. Reaching for the opener, I press the button; the door doesn't open. No big surprise, could be I didn't press the button hard enough, a low battery, a disturbance in the Force. I press it again; nothing. A third time...nothing. Remember that saying about repeating a sequence expecting a different response? I was well on the way there.

So I continue pressing the button, trying different variables of pressure, duration, angle, pointing it in the mirror, nothing. After several frustrating minutes my partner looks at his mirror, then at me and says "Bay 2 is open." I look down at the dash, back up at where I'm parked...doh! In my admiration of the spring sunshine and a beautiful day, I neglected to remember I pulled out of bay 2 for this call. Meanwhile, I'm parked in front of (and demanding that the door to) bay 1 open. The ambulance we're in ALWAYS goes in bay 2.

My partner looks at me and says "Wouldn't it be nice if they put the ambulance number in big letters on the dashboard," pointing at the 3" Scotchlite numbers pasted on the dash in front of him. He and I shared a laugh for a good five minutes before I could muster the ability to park the ambulance in the correct bay.

Finding Balance

After joining the first agency in my career, a small outfit with two ambulances, a pole barn base, and about 20 active members, I jumped in with both feet. I wanted to be a part of everything, wanted to do everything to help out my hometown Corps. This “dedication” drove the other three new members (and most of the vets) nuts. “You need to slow down, or you’re going to burn out.” 18 years old, full of….yeah, those two things…and ready to save lives. After all, that’s what this is all about, right?

Many years later, I often find myself reflecting on those sage words spoken by the elders of my first Corps. At the same time, they were people I admired and utterly despised because I thought they were holding me back. I knew the stuff on the State exam. Even more than some because my father was an EMT for most of my childhood, so I was always around it. I knew what my job and responsibilities were. But what I didn’t know was that I didn’t know it all. The wise elders at my first Corps tried their hardest to tell me, but I was too bullheaded to listen.

My “dedication” drove me out of that first agency in less than a year. I couldn’t find a balance between the “book stuff” and the “real world” stuff.

It wasn’t until a few years later that I finally understood the need to balance my EMS passion with the rest of my life. Yes, I’ve chosen to make EMS my career. No, I don’t make much money doing it. But when you look past the financial part and understand there is so much more to life than “saving lives” and “true emergencies,” the real essence of this job comes out.

A quality professional provider learns to recognize this job is not “all action, all the time” and that a good deal of down time will occur. They learn to take advantage of this time to enhance their knowledge, catch up on a favorite novel, or just kick back and enjoy a few minutes to breathe. In essence, they understand the need to balance the “go” mentality with relaxation and recharging for the next call.

The last, and arguably most important aspect of balance, is that between EMS and the rest of your life. A quality professional will understand that when the day’s over, it’s time to turn off the pager, hang up the scope, and take some time for you. For those who volunteer and respond to calls from home, this can be applied by understanding that you alone are not responsible for handling every call. There are other members of your Corps for a reason. I’m not saying turn off your EMS brain entirely; there’s a chance you could be in the right place at the right time to help someone in need.

This was one of the hardest lessons for me to learn, and I’m sure I’m not the only one. But you have to do it; otherwise the things we see and do in this job will consume you. Spend time with your family, or with friends who aren’t in the fire/EMS/police scene. Start a new hobby…or catch up on an old one.

Establishing a balance between your emergency services life and the rest of your life can be one of the hardest things to do, especially when you’re passionate about the job. But believe me, once you’ve established that balance you will certainly come to appreciate everything you have in your life and how precious life really is.