Having an issue with Documentation and Charting

[EchoMikeTango]

So there is a HUGE issue here at work, and I am gonna bring it to your attention.

I am currently writing an email to the chief of my dept.

It has to do with documentation in EMS charts. For those of you that work with this , I would really like your imput. Please help an EMT Brother OUT!!!

here is the letter. i removed the names.


Morning <Chief>,

I feel that i must bring this to your attention in regards to EMS Charts and the documentation policies. First, I have an issue with the chief complaint box and the duration box.

I have been told by <Dep. Chief> that the Chief Complaint is what the patient tells you is wrong. I have no issue with that. I totally agree with that, unless the PT cannot tell you what is wrong or refuses to.

I have done some research as to what the definition of Chief Complaint is . The general consensus on several websites, and polls of several EMS, and Medical professionals will state that a Chief Complaint is a subjective statement made by a patient describing the most significant OR serious symptoms or signs of illness or dysfunction that caused him or her to seek health care.

For instance, say you have a
--1 year old with a febrile seizure. I am told that the Chief Complaint is " None Voiced " . I am also supposed to put a duration of the CC on page 2. And then on Page 1 I am to put the onset.
or
--You have a 35 yom who fell down a flight of stairs, and is unconscious broken femur , with large amount of bleeding . I am told that his chief complaint is "none voiced" .
or
-- Someone who can’t speak, maybe due to respiratory distress. So I am to put that there chief complaint is " None Voiced" or you could type "Unable to voice due to patient being in respiratory distress."

These are very conflicting issues, and I feel that they are not being resolved or addressed at the downstairs level. I have spoken to <Dep. Chief> about this. She stated that <EMS CHARTS ADMIN > says it is supposed to be what the PT states, yet I had to ask almost a week after of what the status was. I am not ok with this. I feel that it is not representing a proper account of the event / contact with the patient. I also feel that this is a large issue and it shouldn't be brushed off the way it was.

This is causing some serious issues with the staff as well, and I believe it to be paramount that we have a meeting to discuss documentation.

Another issue that i have noticed with EMS charts, is that people don't understand that pages 1 - 5 are our observations of the event. They are putting there oxygen application and immobilization in this area, when it belongs in the activity log.

I understand that <EMS CHARTS ADMIN > is very busy, but these issues have been getting worse over the past few months, and I feel that my concerns are being neglected. I feel that the "user manual" is not an accurate way to teach people how to do EMS charts. I strongly recommend that we have a meeting and have the ability to voice our questions and concerns.

 

[Veneficus]

I think you are thinking too hard on this.

 

[EchoMikeTango]

Oh. I totally agree with you. However, the Q&A's on this topic are driving me crazy.

 

[Veneficus]

I usually write the nature of the illness or what the patient complains of in as few words as possible.

 

[mycrofft]

My take on it (RN and former EMT)

Chief Complaint is usually what the patient complains about. ("S" for subjective). If the pt cannot complain, use what the person calling says, or another credible witness. This fixes what you had as a starting point for your assessment, and the basis for the dispatch (maybe). (If there is no one there, maybe put "per dispatch, man down on corner" or some such).

Your recording should show what your assessment(s) revealed (findings, not a diagnosis), and what measures you took, maybe with a reference to which protocol. Unless your boss says differently.

S: Bystander states subject fell down stairs, lost consciousness, was dragged to bottom of stairs by other bystanders.
O: (VS), (GCS), unresponsive to painful stimuli, left thigh bent at mid-femur with decreased distal pulses and pallor.
P: Spinal precautions, support vital signs (IV if its in your protocols, stating which solution/rate/site and # of attempts), measures to immobilize leg for transport (can you use traction splint on spine board? Use SEARCH we chatted that one to death).Plus anything else on your protocol; if protocol is violated, be sure to state why (i.e., "Traction splint not used due to potential spine injury and incompatibility of measures").

Somewhere you need time on scene, time measures started, time off scene and time at receiving facility. Even if it is only on your 59cent spiral pocket notebook.

Some people think "COMPLAINT" is equivalent to a diagnosis. If your company is documenting that way, fine, but get the diagnosis from the ER MD or state it such as "SUSPECTED femoral fracture and closed head injury". That square is likely used for billing info and they want that data asap to start billing for services.

There are other recording systems, but even if you were reduced to doing it with a crayon and binder paper, this would work.

 

[NYMedic828]

I use EMS charts, and as a side note it has a lot of totally non EMS related fluff in it, that needs major revising.

There is no reason arterial line should even be an option under treatments amongst about 20 other things done at a doctor level, in a real medical environment.


Anyway, as Ven said, this seems kind of ridiculous as a question, no offense.

If a patient cant speak for themselves, The chief complaint is the reason the ambulance was called. Nothing more, nothing less.

From an EMS charts standpoint, your chief complaint can usually be one word like syncope, and then you write a descriptive in the history of present illness box below it...

 

[mycrofft]

PS: good luck as a lowly peon calling the chief out on something like this.

 

[EchoMikeTango]

Not a lowely peon. Im the Operations Officer.

and I am agreeing with you guys. I feel that it too, it a stupid to question. But, this is what I get flagged for everyday. Furthermore, I have to flag my staff on these issues as well. If I let it go, I get called to the carpet, and scolded because I didnt do a good enough job.

 

[Veneficus]

Anyway, as Ven said, this seems kind of ridiculous as a question,.

That is not what I meant.

I mean that of all of the things to bother the chief about or call a meeting on, this is probably better solved by asking some peers.

If they want something different than what you are doing or what other members of your department are doing, somebody will probably say something or hear about it.

 

[Veneficus]

Not a lowely peon. Im the Operations Officer.

and I am agreeing with you guys. I feel that it too, it a stupid to question. But, this is what I get flagged for everyday. Furthermore, I have to flag my staff on these issues as well. If I let it go, I get called to the carpet, and scolded because I didnt do a good enough job.

If somebody is flagging you or calling you on the carpet surely they told you what they want?

 

[EchoMikeTango]

If somebody is flagging you or calling you on the carpet surely they told you what they want?

yes. But i dont agree with it. Did you even read my letter?1

 

[jemt]

If they can verbally state their CC i put it in. If they can't, I look for what their medical emergency is.

IE: Pulseless and apenic for a cardiac arrest.

IE: unconcious/unresponsive for an OD or ETOH.

 

[Veneficus]

yes. But i dont agree with it. Did you even read my letter?1

I read the letter.

It looks like there is some question as to what should be written in the cc box.

Whether or not you agree is sort of a secondary concern.

Some places has a finite selectable list for CC. Mostly done for billing.

If the dep chief told you something I would think they have a reason for why they want it done that way.

I do not see a reason presented.

Is it a personal opinion? A previous conceived understanding? A billing issue? Medical direction? What is the reason it is a concern?

 

[EchoMikeTango]

The reason it is a concern, is that for the Unresponsive person in cardiac aresst, I am to put his Chief complaint at NONE?

If I put PT is in Cardiac Arrest.... I am wrong, and it gets flagged.

 

[jemt]

The reason it is a concern, is that for the Unresponsive person in cardiac aresst, I am to put his Chief complaint at NONE?

If I put PT is in Cardiac Arrest.... I am wrong, and it gets flagged.

Well, I would view NONE in the CC box as implenting its a public assist with no complaint/or injury.

If someone is in cardiac arrest, its implied conset without a physical DNR present so I write their CC as being pulseless and apnec.

 

[EchoMikeTango]

Exactly. but if I put that in the Chief Complaint box. I am wrong. they tell me " A PT cant tell you that they are pulseless and apnic. If they tell you that, then they are alive."

hence the letter....

 

[jemt]

Exactly. but if I put that in the Chief Complaint box. I am wrong. they tell me " A PT cant tell you that they are pulseless and apnic. If they tell you that, then they are alive."

hence the letter....

I was never taught nor corrected for putting the implied conset in the CC box when the pt. isn't verbally able to state it.

Is this a private for profit service? Sounds like a billing issue.

 

[EchoMikeTango]

When i asked about the billing issue. They said it has nothing to do with billing. It has to do with.... and then I get blank stares as if I just asked them to solve cold fusion...

 

[Veneficus]

When i asked about the billing issue. They said it has nothing to do with billing. It has to do with.... and then I get blank stares as if I just asked them to solve cold fusion...

So you wrote a letter for clarification to people who have no idea what they are talking about?

I might start looking for employment at an agency of a higher caliber.

 

[d0nk3yk0n9]

We were told in our service (we also use EMSCharts) to put "Unresponsive" or something to that effect if the patient is unresponsive and cannot tell us a chief complaint.

We were also told that we could, in some cases, summarize what the patient would have told us, if they were capable. So, for example, for an ETOH patient who is responsive to verbal stimuli but not able to communicate a chief complaint, we usually write something like "I drank too much" as the patient's chief complaint.

"Altered Mental Status" would also be a valid description in many cases.