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How to write a patient care report

Posted on by SafetyPros in In-Service, Lifeguard, Professional Rescuers, Rescue, Title 22 Leave a comment

Many emergency responders including Lifeguards, complete a patient care report on the incidents they respond to. Responders involved in the incident need to complete the appropriate report form as quickly as possible after providing care. Record only factual information of what was heard and seen and any action taken. Do not give personal opinions.

Documentation is important for legal reasons as well as for tracking when, where and how often incidents occur. Reports provide valuable information for facilities to use when they assess safety protocols, such as staffing levels or placement of lifeguard stations.

Here is a checklist of questions providers should answer before submitting a report:

  • Are your descriptions detailed enough?
  • Are the abbreviations you used appropriate and professional?
  • Is your report free of grammar and spelling errors?
  • Is it legible?
  • Is the chief complaint correct?
  • Is your impression specific enough?
  • Are all other details in order?

 

1. Check descriptions
Upon the completion of every incident, your report documents all events that occurred. This includes a detailed assessment of the situation and a full recounting of the treatment administered to the patient. It is specific, informative, free of ambiguity and negligence.

  • Which arm is the patient having pain?
  • Is it the upper or lower part of the arm?
  • What was the timeline of the incident?

 

2. Check (and recheck) spelling and grammar

Your report should paint a picture, but this is impossible to do without proper English. Besides not being accurate or professional, incorrect English may very well lead a reader to believe something false. For example, there may be confusion (and laughter) if a report says “patient fainted and her eyes rolled around the room.” Though this is a humorous example, dire consequence can follow confusing reporting.

Reporting should be free of misspellings and the understanding of what you are trying to say should be clear. For example, the trauma surgeon should have a good understanding of the mechanism of injury that brought the patient to the hospital from reading your report.

3. Assess your chief complaint description
An area of the report that is frequently misused is the chief complaint which should explain why you were needed or why the patient is being treated. Chief complaint is not the cause of the injury. For example, a chief complaint is pain to the right lower arm, not the fact that the patient has fallen off a ladder. Using the patient’s own words is an appropriate practice if they describe symptoms of their chief complaint.

4. Review your impressions
An impression encompasses the reasons for patient treatment. Trauma and fall are too vague to be used as impressions. Include the body areas or symptoms that are being treated. In other words, what treatment protocol is being followed?

If you are following a stroke protocol, and your assessment indicates a possible stroke, this should be included in your impression. Multi-systems trauma injuries bring additional challenges, but if multi-body systems are involved, they all should be included in your impression of the patient.

5. Check the final details
The patient’s SAMPLE including past medical history and medications are important to note. Document the patient’s history completely. Remember bystanders or those close to the patient can often provide valuable information about the patient.

Another important aspect to clearly document is the outcome of your treatments. Some reports have a standard text box that indicates improved, but in your narrative you should clearly document how the treatment improved the patient’s condition.

After the incident and upon completion of the report writing, you may be asked to attend an operational debriefing. The goals of the debriefing are to examine what happened, assess the effectiveness of the EAP, condier new ways to prevent similiar incidents and to be alert for stress reactions after a critical incident. Be sure to avaoid assigning blame or criticizing anyone’s actions or reactions.

For additional in-service training at your facility, contact the rescue professionals at Safety Training Pros 844-900-SAFE (7233).


California New AED Laws Senate Bills 658 and 287

Posted on by SafetyPros in AED, CPR, CPR for Business, Rescue Leave a comment

An automated external defibrillator (AED) is a lightweight, portable device that delivers an electric shock through the chest to the heart. The shock can stop an irregular rhythm and allow a normal rhythm to resume in a heart in sudden cardiac arrest. Sudden cardiac arrest is an abrupt loss of heart function. If it’s not treated within minutes, it quickly leads to death. AED’s make it possible for more people to respond to medical emergencies where defibrillation is required. Because they are portable and easy to use, they can be used by nonmedical people. They should be a part of your emergency response plan that also includes the use of 9-1-1 and prompt delivery of cardio pulmonary resuscitation (CPR).

There are a variety of law regarding AEDs. Recently, California has enacted two, new AED laws (Senate Bills 658 and 287), the second of which was just chaptered into California law October 2, 1015.

S.B. 658 amends section 1714.21 of the CA Civil Code and section 1797.196 of the CA Health and Safety Code to substantially reduce the requirements placed upon AED owners to qualify for Good Samaritan protection in the state.  Most notably, the new law eliminates the need for a physician to oversee a company’s AED program. This will significantly drop cost of ownership as well as reduce the inconvenience factor of owning an AED. In addition, the new law reduces the frequency with which AED owners need to check their devices and pares back documentation rules.

S.B. 287 installs mandates across a sweeping array of building types (assembly, business, educational, factory, institutional, mercantile, and residential) that, effective 1/1/17, will require AEDs in all new construction, generally subject to an occupancy threshold of 200 people.

For more information about purchasing an AED for your workplace, or to arrange training for your staff, call 844-900-SAFE.