Communications and documentation
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This document provides guidelines for Chapin Area Rescue Squad personnel on dispatch, response, on-scene operations, transporting patients, and documentation for emergency medical calls. Key steps include acknowledging dispatch pages, notifying the hospital of response and arrival, obtaining patient information, notifying the hospital of transport and estimated time of arrival, following treatment protocols, obtaining required signatures, and properly documenting all aspects of patient care. Proper communication and documentation are emphasized as important for legal protection, quality improvement, and reimbursement.
Communications and documentation
- 1. Communication Documentation Legal Aspects Chapin Area Rescue Squad/Spring 2013/B. McCormick EMT-P
- 2. Dispatch • Upon receipt of the dispatch page, one member shall acknowledge the page on MCERN. This only needs to be done once. • After the page has been received, all members available shall switch to Chapin Fire Frequency if it is available, announcing by name or CAR number they are available • If anyone is unable to change radio channels or has a pager, continue to respond to the Rescue Station • Once a significant crew is reached (as determined by the highest trained individual) the CARS will respond to the emergency • If you will be responding to the scene of the medical emergency, attempt to call or notify the CARS members going enroute over the radio.
- 3. Response • Notify PAH that 3H11 or 3H99 is enroute via MERCI. • The crew can then begin the size up and assignment of patient care responsibilities. The treating EMT or Paramedic will be the primary patient care provider, unless he/she decides otherwise. • For medical calls, upon arrival the driver will notify PAH of arrival on scene. • For trauma calls, upon arrival the driver will notify PAH of arrival, and switch to Chapin Fire frequency and give a scene size up consisting of: • Number of vehicles involved • Location of patients • Number of patients if known • Best place for FD rig blocking
- 4. On Scene • Once on scene one responder will be responsible for obtaining the information on the assessment sheet. • Typically this will be accomplished by the treating EMT or medic asking questions and the scribe making annotations. The scribe can also get the patient’s medications at this time.
- 5. Transporting • At this time the driver will notify PAH of transporting to their location or other facility via MERCI. Ensure to tell the telecommunicator if transport will be BLS or ALS and estimated time to arrival (ETA). • Treatment will be based on medical or traumatic injury. For stable patients vitals will be every 15 minutes. • If transporting BLS, you must call PAH ECRN with patient assessment. • The LifePak 15 can be used for all Vitals after the manual baseline VS are taken. • If you are starting transport BLS and will upgrade to ALS, or the patient develops chest pain, prepare to obtain a 12 lead ECG, and have the driver pull over to obtain the ECG.
- 6. Calling the ECRN • Use the following format when calling the ECRN for any receiving hospital.
- 7. Arrival at the Hospital • Move the patient from the ambulance to ED • The person treating the patient will give report to treating RN. This report will be very similar to the radio report. • The driver will then fill out the EMS re-stock form, and gain RN signature and patient ID sticker from hospital personnel. • The EMT or medic treating will start the ePCR via the iPad. • See iPad training that will be in iPad cases.
- 8. ****SIGNATURES**** • Medicare has become very particular about signatures in 2013. This will be REQUIRED for Medicare and Medicade payment. • The patient MUST sign if they are CAO to person and place • RN MUST sign for all patients. They then need to print their name. They must also put the RN behind either name. • If the patient cannot sign, and a POA, parent, or guardian signs, they will need to both sign and print. Additionally, they MUST ALSO PUT IN THEIR address!
- 9. Importance of Documentation • The legal document used to identify all aspects of emergency medical care • Used to identify training needs or deficiencies. • Assist in recalling the event or incident years later if called to court • May be the best defense or worst witness if called to the stand • Assist with agency billing and being able to improve the services able to provide.
- 10. Conclusion • In addition to communicating with other responders, telecommunicators, RNs and MDs, we must use proper tone, body language and inflection when dealing with patient populations • If you have any questions, call medical control sooner than later. • Proper documentation may take a few minutes longer the day of the transport, but will pay dividends if every called to court. • Always remember you are working on a legal document and be sure to spell out all words. Only the abbreviations found for the state of Illinois EMT and Medic exams are allowed on the PCR. If you do not know what all of them are, spell out the word!