ESO Doc

1. Documentation

2. Responded from st to above location for male pt with respiratory problems. AOSTF 90 y/o male
sitting upright in chair c/o minor headache and nothing else. EMS ran on same pt earlier this
morning and obtained refusal. Pt's wife states that she is very tired of taking care of pt and that
she wants him taken to the ER. Pt states that he is fine, does not need an ambulance but that his
wife is too worried about him.

3. QA Messages
Captain
◦ Documentation Errors
◦ Spelling
◦ Manual VS
BC Swisher
◦ Missing treatment
◦ Wrong drug
◦ Wrong dose
◦ Other clinical errors

4. Incident
EMD Code
◦ If none given, no guessing
Disposition
◦ Lights & Sirens
Times
◦ Staging – On Scene
◦ At Patient – At Patient
Delays
◦ Please Use

5. Vital Signs
Delete bad ones
2 complete sets
◦ 1 manual
◦ Side, LOC, Position
◦ BP, PR, RR
◦ GCS, Pain
12-lead w/ diagnosis

6. Sample Chest Pain Stats
January 1, 2014 – April 30, 2014
◦ Chest Pain – 216
◦ MI-STEMI – 16
◦ Cardiac Rhythm – 46
◦ CHF – 6
◦ 12-Leads – 142
◦ 3-Lead – 42
◦ Stretcher – 40
◦ STEMI Alert - 6

7. Flowchart
Most Mis-Charted Items
◦ 12-Lead ECG
◦ ETCO2
◦ 3-Lead
◦ Stretcher
◦ Mechanical CPR

8. Assessment
Initial & Ongoing on all transports
Use text boxes for pertinent negatives

9. Narrative
Primary Impression
◦ If transfer, reason pt went to hospital
◦ If transported, MUST HAVE IMPRESSION
◦ Do not use No Injury, No Illness
Only put pt says “….” if pertinent.
◦ Avoid curse words
Start with
◦ Responded from…..
Use “as above”
◦ Vitals as above
◦ Treatments as above
◦ Assessment as above

10. Other important info
Med/Hx/Allergies
◦ Don’t need to use list

11. Specialty Patients
Stroke
◦ Time of onset important but not required
STEMI
◦ Necessary if STEMI
CPR
◦ Check the boxes

12. Notes from Bec
Get insurance info from FACE sheet
SCAN!!!!

13. Any Questions?