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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).


October is Sudden Cardiac Arrest Awareness Month!

Posted on by Trainer in AED, CPR, General, Rescue, Training Leave a comment

Did you know that sudden cardiac arrest takes the lives of over 300,000 Americans each year? According to Mary Newman, SCA Foundation president, “About 500 Americans suffer sudden cardiac arrest every day and only 30 survive.”

What is Sudden Cardiac Arrest?

According to Heartsine.com, Sudden Cardiac Arrest (SCA) is a malfunction of the heart’s electrical system, which causes it suddenly and unexpectedly to begin to beat rapidly, then erratically, and finally to stop altogether. When this happens, the heart cannot pump blood effectively. As such, blood flow to the brain is compromised and the victim quickly loses consciousness.

What can we do to increase the survival rate?

  1. Get CPR/AED Certified
  2. Have better access to AED’s

Where can I get this type of Training?

Safety Training Pros is the premier safety training experts for individuals, groups, businesses, and government agencies.We provide professional training with high quality safety training materials in an engaging atmosphere so our clients have the life saving skills and knowledge that they need in an emergency. As a Licensed Training Partner of the American Red Cross, ASHI, and Medic First Aid, the leading providers of health and safety training, we can easily and efficiently provide the quality professional training required by all our customers. This includes, but is not limited to, CPR and AED training. Please call us for more information at 844-900-SAFE or visit us at safetytrainingpros.com.

 

 

 


Hypoxic Blackout in Aquatic Activities is Deadly Serious

Posted on by SafetyPros in Aquatics, General, Lifeguard, Professional Rescuers, Rescue, Training Leave a comment

The practices of hyperventilation preceding underwater swimming and extended breath-holding in the water are dangerous and potentially deadly activities. These activities can put the body in a state of hypoxia—a condition in which the body is deprived of adequate oxygen supply. It is our goal to educate those that we teach about the risks of hypoxia in the water and help ensure that they do not engage in behavior that could result in loss of consciousness and death. This includes lifeguards, Water Safety instructors and swim coaches, participants in a learn-to-swim program and their parents as well as the general public who engage in aquatic activities.
The result of these activities is referred to by some as “shallow water blackout.” The use of this terminology in these cases is misleading since water depth is not a Swim Coachfactor in the body’s response to hyperventilation and extended breath-holding. Shallow water blackout is the medical condition that can result as a deep water diver returns to surface and blacks out in water that is typically less than 5’ deep. There are specific precautions and prevention strategies for this condition.
In an effort to be more clear and accurate, Safety Training Pros will not use the term shallow water blackout. In our training programs and public education, we use terminology that describes the dangerous behaviors that should be prevented—voluntary hyperventilation preceding underwater swimming and extended breath-holding. For simplicity, we refer to this condition as hypoxic blackout.
Water Safety

Lifeguards, instructors and coaches are trained to be alert and prevent swimmers attempting to hyperventilate and engage in extended breath-holding activities. Lifeguards are taught to respond quickly to any individual who is motionless in the water for any reason, including loss of consciousness. Water Safety instructors are also taught to limit participants to a single inhalation whenever they ask participants to hold their breath and submerge, and to set safety limits whenever setting up activities that involve underwater swimming. Being confident and comfortable underwater is an essential aquatic skill. Knowing what breath holding techniques are unsafe is important in exercising good judgment for safe skill practice and supervision of underwater aquatic activities.

 

Stay safe this summer and remember When Every Second Counts, Your Training Matters!