Effective: 11-01-20
Supersedes: 01-01-18
Purpose: To define and describe indicators utilized in the review of documentation of the written clinical record.
Goal: To provide excellent documentation of the patient encounter form and to continually seek improvement and revisions as needed.
Standard: The QA designee will review 40% of the encounter forms within 48 hours of a patient transport. Quarterly reports will be generated for the organization in expectation of improving documentation of the clinical record.
Clinical Indicators
All clinical records will be reviewed for the following:
1. Run number and service date
2. Crew information
3. Response information
4. Patient Disposition
5. Call times
6. Patient information/demographics
7. Next of kin contact information
8. Insurance information
9. Past medical history including allergies and cause of injury
10. Body survey diagram for visual injuries
11. All patients encountered will have documented vital signs a minimum of every 10 minutes to include time, blood pressure, heart rate, respiratory rate, Spo2, Etco2, blood glucose and GCS. Continuous oxygen saturation and cardiac monitoring will be noted.
12. At a minimum, a Glasgow Coma Scores will be noted and accurate based on the clinician’s subjective evaluation.
13. An EKG strip with capnography waveform if appropriate will be affixed to the medical record
14. IV crystalloid volume will be noted including the type of IV fluid.
15. IV medication will be addressed and documented.
16. Subjective assessment will include information regarding treatment rendered by the sending care providers including medications administered, procedures either attempted and/or accomplished, the patient’s presenting history, labs obtained and lab values reported, radiographic evaluation and findings.
17. Objective assessment will include a short description of the patient’s presentation and a physical examination to include:
a. Neurological exam: patient’s level of consciousness, pupillary size and reactivity, evidence of sensory/motor deficits, seizure activity and movement of extremities.
b. Respiratory exam: natural or artificial airway, respiratory rate lung sounds, oxygen administration.
c. Cardiovascular: cardiac rate and rhythm, capillary refill time presence or absence of pulses, intravenous access, size, site and patency & type of fluid. Gastrointestinal exam: physical exam of abdomen, presence of a gastric tube including gauge, presence of nausea
d. Genitourinary exam: presence of a urinary catheter.
e. Musculoskeletal/Integumentary: exam if applicable.
f. Psychiatric/Social History: to include presence of family members and their awareness of the patient transfer
18. An assessment including known or suspected diagnosis
19. Plan of Care listing appropriate given or expected interventions including
a. Time of Intervention consistently documented.
b. Patient’s response to intervention documented.
c. Appropriateness of interventions performed or omission of needed interventions.
20. Patient’s change in condition during transport.
21. Transfer of the complete medical record and report to receiving Facility.
Artificial Airway
The clinical record for the patient with an artificial airway will be reviewed for the following:
1. Subjective assessment will include attempts at airway management by other clinicians to include medications utilized and number of attempts at definitive airway placement if known, patient subjective complaints of respiratory distress
2. Objective assessment will include estimate of the patient weight and
a. Neuro: general documentation standard
b. Resp: clinical indicators of respiratory failure/distress to include hypoxia, hypoventilation, soft tissue injury where increased edema may preclude endotracheal intubation at a later time, respiratory fatigue if present
c. Cardiovascular: evidence of metabolic acidosis and poor tissue perfusion
d. Gastrointestinal: presence/absence of a tube
e. GU: general documentation standard
f. MSI: general documentation standard
3. Procedure documentation will include:
a. Notation of personnel that attempted/succeeded in securing the airway
b. Number of attempts if known
c. Type/Size of artificial airway, (oral, nasal, king lt, LMA, retrograde, tracheostomy, cricothyrotomy)
d. Where the patient’s airway was secured (Home, vehicle, roadway, ambulance etc.)
e. C-Spine stabilization if appropriate
f. Securing depth
g. ETCO2/Capnography
h. Medications utilized to assist in securing the airway
i. Breath sounds, chest expansion
j. Absence of abdominal sounds
k. SpO2 nadir during airway management
l. ETT securing device
m. Gastric tube placement
n. Adverse events
o. Reasoning for failed attempts (anatomy, emesis, hemorrhage, tissue damage)
Cardiac Patient
The clinical record for the myocardial patient will be reviewed for the following:
1. Subjective assessment will also include
a. Onset and progression of illness and present level of chest pain/pressure.
b. ECG findings (including R sided leads in an IWMI) and any Dysrhythmias
c. The presence of associated signs and symptoms including diaphoresis, palpitations, nausea, vomiting.
d. Pharmacological therapies and patient response, including ASA, Beta Blockade, Heparin administration, IIb/IIIa platelet inhibitors, Nitrates, thrombolytics
e. CXR and results of other radiographic studies.
f. Laboratory Data (including CPK-MB and Troponin if available)
2. Objective assessment will also include estimate of the patient weight and documentation of findings to include but not be limited to
a. Time of pain onset
b. Neuro: general documentation standard.
c. Resp: lung sounds, respiratory rate, presence of cough or dyspnea, spo2
d. Cardiovascular: hemodynamic values, evidence of JVD, chest pain scale
e. Genitourinary: urine output
f. Gastrointestinal: general documentation standard
g. MSI: general documentation standard
3. Plan of Care listing appropriate given or expected interventions to include but not be limited to:
a. Oxygenate
b. Monitor hemodynamics
c. Titrate crystalloid to heart rate and blood pressure
d. Pharmacological treatment of chest pain/pressure
e. Delivery and titration of hemodynamic medications
f. Apply Zoll multifunction pads
Trauma Patient
The clinical record for the trauma patient will be reviewed for the following:
1. Subjective assessment will also include the mechanism of injury, direction and amount of energy force, known utilization of protective devices, initial patient presentation, BLS/ALS/ sending hospital physiologic findings, BLS/ALS/sending hospital interventions including but not limited to type of vertebral immobilization, subjective complaints of pain.
2. Objective assessment will also include a primary and secondary survey as outlined in BTLS guidelines and documentation of findings to include but not be limited to:
a. Neuro: initial level of consciousness, mentation, presence of defects in skull integrity, comprehensive sensory/motor exam, presence/absence of seizures, headaches.
b. Respiratory: tracheal deviation, chest wall integrity, presence of foreign bodies, or other airway obstruction
c. Cardiovascular: presence of JVD, chest pain or discomfort, peripheral perfusion, skin color, large bore IV access
d. Gastrointestinal: abdominal exam including presence of distention, ecchymosis, punctures or rigidity
e. Genitourinary: pain, meatal bleeding, pelvis stability
f. MSI: presence of abrasions, contusions, lacerations, bony deformity, edema circulatory, sensory and motor exam of extremities if suspected fracture, notation of fracture splints if applicable
3. Plan of Care listing appropriate given or expected interventions to include but not be limited to:
a. Oxygenate
b. Monitor hemodynamics
c. Establish peripheral IV access
d. Cervical spine immobilization
e. Promotion of normothermia
f. Medication/ analgesia administration
g. Wound care
h. Hemorrhage control
Burn Patient
The clinical record for the burn patient will be reviewed for the following:
1. Subjective assessment will also include the mechanism of injury, confined space, duration of exposure, chemical exposure (determine offending agent), electrical contact, (amperage, voltage, type of current, and duration of current) time of burn injury, initial patient presentation, BLS/ALS/sending hospital physiologic findings, BLS/ALS/sending hospital interventions on scene, subjective complaints of pain, patient’s tetanus status.
2. Objective assessment will also include a primary and secondary survey as outlined in ATLS/ ABLS guidelines. Estimate of the patient weight and documentation of findings to include but not be limited to:
a. Neuro: general documentation standard.
b. Resp: assessment of any potential inhalation injury
c. Cardiovascular: delivery of warmed IV fluids
d. Gastrointestinal: presence/absence of a GT
e. MSI: documented location, percent, and depth of burn injury. Utilization of anatomical figure to assist in above.
3. Data entry will include documentation of BLS/ALS times and estimated time of injury
4. Plan of Care listing appropriate given or expected interventions to include but not be limited to:
a. promotion of normothermia; temperature documentation
b. treatment of pain if applicable
c. mode and percentage of O2 delivery
d. initiation of large-bore vascular access if none, delivery of IV crystalloid based on the Parkland formula
e. Transport of patient in clean, dry sheets if large burn
f. Distal pulse checks of affected extremities
Ventilator Patient
The clinical record for the ventilated patient will be reviewed for the following:
1. Documentation of the objective respiratory assessment will include if applicable:
a. Type of ventilation device (vent, bag valve device)
b. Percentage of Oxygen
c. Mode of Ventilation (AC, SIMV, CPAP)
d. Tidal Volume or Pressure utilized
e. Rate of Ventilation
f. Ventilation Rate/Total Rate
g. Presence and amount of peak end exp pressure (PEEP)
h. Presence and amount of pressure support (PS)
i. Peak inspiratory pressures (PIPS) j. I/E ratio
j. Etco2
Obstetrical Patient
The clinical record for the obstetrical patient will be reviewed for the following:
1. Subjective assessment will also include
a. maternal age
b. last menstrual period
c. estimated date of confinement
d. History of hypertension, diabetes or edema
e. Previous OB complications
f. Previous pregnancies/deliveries
g. Possibility of multiple births
h. presence of vaginal bleeding
i. presence or absence of ruptured membranes
2. Objective assessment will also include an obstetrical exam consisting of
a. Presence of contractions
b. Fetal heart rate (presence/absence of decelerations (early, late, variable)
c. Dilation/effacement status
d. Fetal presentation
e. Membrane status (intact, ruptured, time or rupture)
f. Maternal blood type
g. Ultrasound data if available to include estimated fetal weight & position
h. Prenatal care
3. Plan of Care listing appropriate given or expected interventions to include but not be limited to:
a. Patient positioning
b. Uterine contraction assessment (frequency, duration, maternal response)
Neuro Patient
The clinical record for the neurologically impaired/injured patient will be reviewed for the following:
1. Subjective assessment will also include, if known when the patient was last confirmed to be at normal baseline, initial neurological exam on presentation, results of radiological and laboratory studies to include CT: presence and place and size of abnormality, mass effect, time of CT, coagulation studies.
2. Objective assessment will also include but not be limited to
a. Neuro: time of onset, initial level of consciousness, GCS, cranial nerve assessment, motor and sensory exam, visual disturbances, quality of speech.
b. Resp: respiratory rate and pattern
c. Cardiovascular: general documentation standards
d. Gastrointestinal: general documentation standard
e. Genitourinary: general documentation standard
f. MSI: general documentation standard
3. Plan of Care listing appropriate given or expected interventions to include but not be limited to:
a. Monitor mentation
b. Oxygenate
c. Monitor hemodynamics
d. Continue/titrate medications and infusions
e. Monitor Etco2
Medication Administration
The clinical record for any patient receiving a medication(s) will be reviewed for the following:
1. Documentation of the subjective assessment will include if known:
a. Name of medication(s) given prior to arrival
b. Amount of any medications given prior to arrival
2. Objective assessment will include
a. Current IV medications and the rate of administration
3. Any medications delivered by Brewster Ambulance Service will include
a. Name of medication
b. Amount of medication
c. Route of administration (IV, IO, ETT, IN, SL)
d. Rate of administration if applicable
e. Initials and ID number of person who administered medication
f. In the event of IV solutions, site of administration will also be noted
g. Presence/absence of any effect/adverse reaction the medication
4. Administration of Blood Products will also include
a. Type of blood product
b. Unit number of blood product
c. Physician’s name who ordered the transfusion
d. Presence/absence of any adverse/side effects to the transfusion
e. Amount of blood product administered during the transport
f. Patient's baseline temperature prior to blood administration
Controlled Substance Administration
The patient encounter form and the drug log will be checked for the following:
1. Controlled Substance Record
a. Oncoming ALS personnel will complete and review the drug log for all required and scheduled medications.
b. The Field supervisors will review all controlled substance records for compliance with the above standards and general medication storage and maintenance.
c. Medications utilized during patient care will be formally documented and recorded will be the reason for use, effects of the medication administration and any adverse reactions associated with the medication administration.
d. Following the transfer of patient care to the receiving facility a medical record will be generated to replace the medications used at the appropriate pharmacy.
2. Refilled narcotic boxes may be resealed at the pharmacy or by the crew/supervisor.