EMS REPORT FORM TRAINING MANUAL

EMS REPORT FORMTRAINING MANUALLos Angeles CountyEmergency Medical Services AgencyRevised:March 2014

EMS REPORT FORM TRAINING MANUALMarch, 2014Table of ContentsINTRODUCTION . 3HOW TO USE THIS MANUAL . 5REPORT COMPLETION. 7GENERAL GUIDELINES . 11HOW TO MAKE CORRECTIONS. 12BEFORE COMPLETING THE RUN . 13DISTRIBUTION OF COPIES . 14INCIDENT INFORMATION . 16PATIENT ASSESSMENT . 23GCS/mLAPSS. 29SPECIAL CIRCUMSTANCES. 31THERAPIES . 32TRANSPORT . 0PATIENT INFORMATION. 8COMMENTS. 10COMPLAINTS . 14MEDICAL SUBSECTION. 15TRAUMA SUBSECTION . 21TRAUMA COMPLAINTS . 21MECHANISM OF INJURY. 25COMPLAINT/MECHANISM OF INJURY CODE INSERTION . 30PHYSICAL . 33PUPILS . 331

EMS REPORT FORM TRAINING MANUALMarch, 2014RESPIRATION . 34SKIN. 35CAP REFILL . 3612 LEAD ECG . 36VITAL SIGNS. 37MEDICATIONS/DEFIBRILLATION . 39ECG CODES. 40MEDICATION/DEFIBRILLATION CODES . 42PRN MEDICATION AND NARCOTIC WASTE . 45CARDIAC ARREST . 46REASSESSMENT AFTER THERAPIES &/OR CONDITION ON TRANSFER. 49SIGNATURES . 50MULTIPLE CASUALTY INCIDENT FORM (MCI) . 51ADVANCED LIFE SUPPORT (ALS) CONTINUATION FORM . 58APPROVED ABBREVIATIONS . 66GLOSSARY OF TERMS . 762

EMS REPORT FORM TRAINING MANUALMarch, 2014INTRODUCTIONDocumentation should reflect the standard of care in the community andjustify the services rendered. The goal is to provide a form that facilitatespatient assessment, encourages documentation of treatment, promptsreassessment after intervention, reduces liability, and ultimately improvespatient care.The EMS Report Form is a medical, legal, and datacollection document.THE EMS FORMPROVIDES: Healthcare personnel with an irreplaceable source of vitalmedical information and a foundation for further treatment. Agencies with an operational record to monitor responsetimes, efficiency of service, cost of operations, and whetherthe community standards are being met. Billing departments with information to justify cost of services. Courts with an official document. Poor report completion canlead to costly awards. Insurance carriers, defendants, orplaintiffs in criminal or civil liability cases may use it.3

EMS REPORT FORM TRAINING MANUALMarch, 2014 Law enforcement personnel with pertinent information wheninvestigating child or elder abuse, rape, intimate partnerviolence, and death by questionable means. Government agencies, coroners, community health agencies,HAZMAT teams, and researchers with specific information. A continuous quality improvement tool for use by provideragencies, hospitals, specialty centers and the EMS Agency.In order to examine whether a given EMS systemcomponent, medical procedure or system modification isbeneficial for patient outcome, the provider must collect therequired elements in a consistent fashion for data entry.The Trauma and Emergency Medical Information System(TEMIS) provides for standard data collection and is acentralized EMS data registry, managed by the Los AngelesCounty Emergency Medical Services Agency. Justification for care rendered.Precision in documentation reflects quality in care4

EMS REPORT FORM TRAINING MANUALMarch, 2014HOW TO USE THISMANUALThe explanations in this book are grouped in sections, each representing aportion of the EMS Report Form. The sections are as follows: INCIDENT INFORMATION PT ASSESSMENT GCS / mLAPSS SPECIAL CIRCUMSTANCES THERAPIES TRANSPORT PATIENT INFORMATION COMMENTS COMPLAINTS PHYSICAL o Pupilo Respo Skino 12LeadVITAL SIGNS MEDICATIONS/DEFIBRILLATION CARDIAC ARREST5

EMS REPORT FORM TRAINING MANUALMarch, 2014 PRN MEDICATION and NARCOTIC WASTE REASSESSMENT after THERAPIES and/orCONDITION on TRANSFER SIGNATURES MULTIPLE CASUALTY INCIDENT FORM (MCI) ALS CONTINUATION FORM6

EMS REPORT FORM TRAINING MANUALMarch, 2014REPORTCOMPLETION WHENAn EMS Report Form must be completed for every EMSresponse (one form per patient). A provider agency mayelect to submit a quarterly volume report to the EMS Agencyfor the following types of calls, in lieu of an EMS Report form:a. Canceled callsb. No patient foundc. False alarms BY WHOMParamedic/EMT personnel from the first responding provideragency shall complete one approved local EMS Agency formfor every 9-1-1 patient response, which includes thefollowing:a. Regular runsb. Dead on Arrival (DOA); patients determined orpronounced dead per Los Angeles County PrehospitalCare Manual, Reference No. 814, Determination/Pronouncement of Death in the Fieldc. ALS Interfacility Transfer patientsIn the event of a mutual aid incident, when two firstresponding agencies have responded and each havecompleted an EMS Report Form for the same patient, eachprovider agency shall legibly write the Sequence Number7

EMS REPORT FORM TRAINING MANUALMarch, 2014from the other provider’s form in the space provided for theOriginal Sequence Number. Do not cross out or line throughthe imprinted Sequence Number.If care is transferred from one ALS provider agency toanother ALS provider, each provider agency shall completean EMS Report Form and legibly handwrite the SequenceNumber from the other provider’s form in the space providedfor Original Sequence Number. Do not cross out or linethrough the imprinted Sequence Number. WHEREThe EMS Report Form should be completed at the scenewhenever possible. If unable to complete at scene,additional time should be taken to complete it at the receivingfacility. A complete report shall accompany the patient. WHYThe EMS Report Form is a medical record of care provided.It is the only written document which can reflect the conditionand justify treatment/transport of the prehospital patient at thetime of accident or illness. A re-creation of prehospitalevents should be easily accomplished with a complete andaccurately documented EMS Report Form.A properly completed EMS Report Form should enable youto re-create the incident after the fact.An accurate and complete EMS Report Form may be utilized to: Assist the emergency department staff gather additionalpatient information after paramedics have left the hospital.8

EMS REPORT FORM TRAINING MANUALMarch, 2014 Assist an EMT or paramedic to recall a long forgottenincident in a court of law. Litigation may occur many yearsafter an incident. Avoid frivolous lawsuits. Attorneys look at incidentdocumentation to determine the validity of a lawsuit. It isdifficult for an attorney to proceed with a claim when themedical record reflects treatment rendered in accordancewith the standard of care. Shift the burden of proof in a lawsuit to the plaintiff, who willneed to prove that the written EMS Report Form is incorrect.Conversely, if information is not documented on the EMSReport Form, it is impossible to prove that it was done.NOTE:Most malpractice law suits involve accusations of negligence, which allegesthat the EMS provider (defendant) did not conform to the Standard of Care.Negligence Consists of Four Elements:1) The EMS provider had a dutyto act.2) The EMS provider breachedthat duty by not conforming tothe Standard of Care required.3) Failure to perform a specificduty was the cause of injury orharm to the patient.4) Actual loss or injury occurredwhich can be measured forspecific damages ( ).9

EMS REPORT FORM TRAINING MANUALMarch, 2014In most cases, the duty to act is easily established. The central issuebecomes whether or not the EMS provider breached the “Standard ofCare”.“Standard of Care”What would a reasonable, prudent EMS provider, with liketraining and experience, do under similar circumstances?The EMS provider’s best defense in a negligence claim isto provide quality medical care in conformance with thestandard of care, and to accurately and completelydocument the care given.10

EMS REPORT FORM TRAINING MANUALMarch, 2014GENERAL GUIDELINESWhen completing the EMS Report Form, remember to: Write or print legibly. Complete the gray shaded area for all responses. Complete all appropriate black sections. Use only accepted medical abbreviations (located in the indexsection). Complete all codes (located on the back of page 2 and 3). Correct errors properly by drawing a straight line through theerror and place your initials next to the error. Use military time.11

EMS REPORT FORM TRAINING MANUALMarch, 2014HOW TO MAKE CORRECTIONSNever erase or obliterate an original record. Draw a single line through anentry so that the original item remains readable. Initial each correction anddocument the date and time any changes are made.Modifications should be made by the person who wrote the initial report,not by someone who did not participate in the response. The signature ofthe person modifying the report must appear on the form in the SignatureSection.If a change is made after copies have been dispersed, photocopy thechange and send it to every receiver, along with a cover letter explainingthe change, requesting that the original copy be replaced by the new one.Do not attempt to reconstruct the original. Fill out a supplemental form anddescribe the incident in more detail, but do not alter the facts. Also,document additional information into the agency’s computerized datasystem, if applicable.12

EMS REPORT FORM TRAINING MANUALMarch, 2014BEFORECOMPLETINGTHE RUNReview the EMS Report Form and check for complete and accuratecontent. The documentation should answer the following questions: Does it contain all the information needed by others who rely onyour record for ongoing patient care? Does it reflect your observations about the patient? Does the treatment fit the observed medical condition of thepatient? Is all care provided completely documented? Can the receiving facility interpret the severity of the patient’scondition and determine the response to treatment rendered? Can the run be re-created at a later date with the informationprovided?“The job is not complete until all the paperwork is done”For additional information concerning documentation of prehospital care,refer to the Los Angeles County Prehospital Care Manual, Reference No.606, Documentation of Prehospital Care.13

EMS REPORT FORM TRAINING MANUALMarch, 2014DISTRIBUTION OFCOPIESThe primary care giver is responsible for the correct distribution of allcopies of the EMS Report Form. Provider Copy (White) – Remains with the jurisdictionalprovider that initiates the form. If a private ambulancetransports the patient without ALS personnel, the ReceivingFacility copy (red) is sent with the transporting team.Additionally, most providers send the EMS Agency copy(yellow) with the private provider transport team where it isused for billing purposes and forwarded to the EMS Agency. Receiving Hospital Copy (Red) – Must be sent with alltransported patients to the receiving facility where it becomespart of the patient medical record. If the patient is nottransported, use is at the discretion of the EMS ProviderAgency that initiates the form. EMS Agency Copy (Yellow) – Must be sent to theEmergency Medical Services Agency. The EMS Agencymust receive the yellow copy of the completed form, within45 days of the last day of the preceding month, to reflect allcare given in the prehospital setting and ensure that all dataelements are entered into the TEMIS database. Supplemental Copy (Blue) – Presented to the Countypharmacist in the assigned County facility(ies) in accordancewith Los Angeles County Prehospital Care Manual,14

EMS REPORT FORM TRAINING MANUALMarch, 2014Reference No. 702, Controlled Drugs Carried On ALS Units,for replacement of any controlled drugs administered to thepatient in the field. If not required for controlled drugreplacement, use is at the discretion of the EMS ProviderAgency that initiated the form.IT IS VITAL THAT COMPLETE ANDACCURATE DOCUMENTATION IS DONEBY THE EMS PROVIDER IN THE FIELD.For additional information concerning form distribution, refer to the LosAngeles County Prehospital Care Manual, Reference No. 608, Retentionand Disposition of Prehospital Care Records and Reference No. 607,Electronic Submission of Prehospital Data.15