Documentation Guidance - Revision history

Treloars: /* ALL PATIENTS */

2024-06-24T13:46:10Z

ALL PATIENTS

← Older revision		Revision as of 13:46, 24 June 2024
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	#LOC (explain abnormals)		#LOC (explain abnormals)
	#OPQRST		#OPQRST
	#At least one set of vitals (before and after treatment as well) (Pulse, B/P, Respiratory rate) (temp, O2 sat, CO2, EKG, etc. as indicated)		#At least one set of vitals (before and after treatment as well) (Pulse, B/P, Respiratory rate) (temp, O2 sat, CO2, EKG, BSL, etc. as indicated)
	#Medical Hx (document if medical alert is present)		#Medical Hx (document if medical alert is present)
	#Explore previous treatment compliance.		#Explore previous treatment compliance.

Treloars at 21:06, 31 January 2018

2018-01-31T21:06:41Z

← Older revision		Revision as of 21:06, 31 January 2018
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	#“Asterixis” non-rhythmic flapping of wrists and hands with arms extended and wrists hyper-flexed (hepatic encephalopathy) (in alcoholic patients)		#“Asterixis” non-rhythmic flapping of wrists and hands with arms extended and wrists hyper-flexed (hepatic encephalopathy) (in alcoholic patients)
	#Acute narrow angle closure glaucoma: dilated, non-reactive pupils, eye pain, decreased visual acuity, blurred vision, pressure over eye, corneal clouding, halos, nausea/vomiting.Caused by certain medications: (ie, sympathomimetics, anticholinergics, antidepressants [SSRIs], anticonvulsants, sulfonamides, cocaine, botulinum toxin), dim light, and rapid correction of hyperglycemia. Trauma.		#Acute narrow angle closure glaucoma: dilated, non-reactive pupils, eye pain, decreased visual acuity, blurred vision, pressure over eye, corneal clouding, halos, nausea/vomiting.Caused by certain medications: (ie, sympathomimetics, anticholinergics, antidepressants [SSRIs], anticonvulsants, sulfonamides, cocaine, botulinum toxin), dim light, and rapid correction of hyperglycemia. Trauma.

			[[Category:Administrative Policies\|0123]]

Treloars: /* 1.23 Documentation Guidance */

2017-06-29T19:10:15Z

1.23 Documentation Guidance

← Older revision		Revision as of 19:10, 29 June 2017
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	== Section 1 - ADMINISTRATIVE POLICIES ==		== Section 1 - ADMINISTRATIVE POLICIES ==
	=== 1.23 Documentation Guidance ===		=== 1.23 Documentation Guidance ===
			The following are lists of documentation guidance for different types of patients. Each list should be considered the baseline documentation for each complaint.
	==== ALL PATIENTS ====		==== ALL PATIENTS ====
	#How patient found (position/location)		#How patient found (position/location)
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	#Interventions by agency		#Interventions by agency
	#How was patient moved to stretcher?		#How was patient moved to stretcher?

	=== Extra Credit ===		=== Extra Credit ===
	#If hypocalcemia is suspected (patient with recent surgery on parathyroid) * (+) or (-) “Trousseaus” (contracture of forearm when B/P cuff is inflated on upper arm)		#If hypocalcemia is suspected (patient with recent surgery on parathyroid) * (+) or (-) “Trousseaus” (contracture of forearm when B/P cuff is inflated on upper arm)

Treloars: /* Extra Credit: */

2017-06-29T18:57:17Z

Extra Credit:

← Older revision		Revision as of 18:57, 29 June 2017
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	#How was patient moved to stretcher?		#How was patient moved to stretcher?

	=== Extra Credit: ===		=== Extra Credit ===
	#If hypocalcemia is suspected (patient with recent surgery on parathyroid) * (+) or (-) “Trousseaus” (contracture of forearm when B/P cuff is inflated on upper arm)		#If hypocalcemia is suspected (patient with recent surgery on parathyroid) * (+) or (-) “Trousseaus” (contracture of forearm when B/P cuff is inflated on upper arm)
	#“Homonymous Hemianopia” Loss of vision on one side in both visual fields (upper and lower) *Caused by a cerebral occlusion		#“Homonymous Hemianopia” Loss of vision on one side in both visual fields (upper and lower) *Caused by a cerebral occlusion
	#“Asterixis” non-rhythmic flapping of wrists and hands with arms extended and wrists hyper-flexed (hepatic encephalopathy) (in alcoholic patients)		#“Asterixis” non-rhythmic flapping of wrists and hands with arms extended and wrists hyper-flexed (hepatic encephalopathy) (in alcoholic patients)
	#Acute narrow angle closure glaucoma: dilated, non-reactive pupils, eye pain, decreased visual acuity, blurred vision, pressure over eye, corneal clouding, halos, nausea/vomiting.Caused by certain medications: (ie, sympathomimetics, anticholinergics, antidepressants [SSRIs], anticonvulsants, sulfonamides, cocaine, botulinum toxin), dim light, and rapid correction of hyperglycemia. Trauma.		#Acute narrow angle closure glaucoma: dilated, non-reactive pupils, eye pain, decreased visual acuity, blurred vision, pressure over eye, corneal clouding, halos, nausea/vomiting.Caused by certain medications: (ie, sympathomimetics, anticholinergics, antidepressants [SSRIs], anticonvulsants, sulfonamides, cocaine, botulinum toxin), dim light, and rapid correction of hyperglycemia. Trauma.

Treloars: /* Extra Credit: */

2017-06-29T18:56:59Z

Extra Credit:

← Older revision		Revision as of 18:56, 29 June 2017
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	#“Homonymous Hemianopia” Loss of vision on one side in both visual fields (upper and lower) *Caused by a cerebral occlusion		#“Homonymous Hemianopia” Loss of vision on one side in both visual fields (upper and lower) *Caused by a cerebral occlusion
	#“Asterixis” non-rhythmic flapping of wrists and hands with arms extended and wrists hyper-flexed (hepatic encephalopathy) (in alcoholic patients)		#“Asterixis” non-rhythmic flapping of wrists and hands with arms extended and wrists hyper-flexed (hepatic encephalopathy) (in alcoholic patients)
	Acute narrow angle closure glaucoma: dilated, non-reactive pupils, eye pain, decreased visual acuity, blurred vision, pressure over eye, corneal clouding, halos, nausea/vomiting.Caused by certain medications: (ie, sympathomimetics, anticholinergics, antidepressants [SSRIs], anticonvulsants, sulfonamides, cocaine, botulinum toxin),~~[10, 11, 12, 13, 14]~~ dim light, and rapid correction of hyperglycemia. Trauma.		#Acute narrow angle closure glaucoma: dilated, non-reactive pupils, eye pain, decreased visual acuity, blurred vision, pressure over eye, corneal clouding, halos, nausea/vomiting.Caused by certain medications: (ie, sympathomimetics, anticholinergics, antidepressants [SSRIs], anticonvulsants, sulfonamides, cocaine, botulinum toxin), dim light, and rapid correction of hyperglycemia. Trauma.

Treloars: /* TASER DEPLOYMENT */

2017-06-29T18:56:08Z

TASER DEPLOYMENT

← Older revision		Revision as of 18:56, 29 June 2017
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	#Last Tetanus shot?		#Last Tetanus shot?

	~~TRAUMA ALERT~~		==== VAGINAL HEMORRHAGE ====
	~~1. Complete Trauma Alert Form~~		#Abdominal pain? (describe) PQRST
	~~2. Follow appropriate benchmarks~~		#Nausea/vomiting
	~~3. Full Trauma Assessment~~		#LMP
	~~4. Interventions~~		#Vertigo? Postural?
	VAGINAL HEMORRHAGE		#Describe (clot, tissue, etc.)?
	1. Abdominal pain? (describe) PQRST		#Amount (estimate)? (number of pads, tampons over what time frame)
	2. Nausea/vomiting		#LOC
	3. LMP		#GCS
	4. Vertigo? Postural?		#Cap refill
	5. Describe (clot, tissue, etc.)?		#Conjunctiva
	6. Amount (estimate)? (number of pads, tampons over what time frame)		#Skin Color/Temp
	7. LOC		#Orthostatic Vitals
	8. GCS		#Interventions by FD/others
	9. Cap refill		#How was patient moved to stretcher?
	~~10.~~ Conjunctiva
	~~11.~~ Skin Color/Temp
	~~12.~~ Orthostatic Vitals
	~~13.~~ Interventions by FD/others
	~~14.~~ How was patient moved to stretcher?

			==== WEAKNESS/CVA ====
			#SEE STROKE / CVA / TIA BENCHMARKS
			#Dysphasic? Aphasic?
			#Onset of signs/symptoms?
			#Confusion, Hallucinations, Stupor, Delirium
			#Vertigo, Focal weakness, Abnormal movements, slurred speech,
			#Patient able to sit up without assistance?
			#Respiratory Effort
			#Lung Sounds
			#New Meds?
			#Headache?
			#Vision changes or visual field issues?
			#Eye deviation?
			#Nystagmus?
			#Pupils
			#Cap refill
			#Conjunctiva
			#Fever?
			#Rash?
			#MEND
			#EKG (12 Lead)
	WEAKNESS/CVA		#MM (tongue)
	1. SEE STROKE / CVA / TIA BENCHMARKS		#Skin color/Temp
	2. Dysphasic? Aphasic?		#Recent illness, travel, visitors, etc.
	3. Onset of signs/symptoms?		#Orthostatic Vitals
	4. Confusion, Hallucinations, Stupor, Delirium		#Nausea/vomit/diarrhea/constipation?
	5. Vertigo, Focal weakness, Abnormal movements, slurred speech,		#BGL
	6. Patient able to sit up without assistance?		#Sepsis Alert? Stroke? Cardiac?
	7. Respiratory Effort		#Interventions by agency
	8. Lung Sounds		#How was patient moved to stretcher?
	9. New Meds?
	~~10.~~ Headache?
	~~11.~~ Vision changes or visual field issues?
	~~12.~~ Eye deviation?
	~~13.~~ Nystagmus?
	~~14.~~ Pupils
	~~15.~~ Cap refill
	~~16.~~ Conjunctiva
	~~17.~~ Fever?
	~~18.~~ Rash?
	~~19.~~ MEND
	~~20.~~ EKG (12 Lead)
	~~21.~~ MM (tongue)
	~~22.~~ Skin color/Temp
	~~23.~~ Recent illness, travel, visitors, etc.
	~~24.~~ Orthostatic Vitals
	~~25.~~ Nausea/vomit/diarrhea/constipation?
	~~26.~~ BGL
	~~27.~~ Sepsis Alert? Stroke? Cardiac?
	~~28.~~ Interventions by agency
	~~29.~~ How was patient moved to stretcher?


	~~***~~Extra Credit:		=== Extra Credit: ===
	1. If hypocalcemia is suspected (patient with recent surgery on parathyroid) * (+) or (-) “Trousseaus” (contracture of forearm when B/P cuff is inflated on upper arm)		#If hypocalcemia is suspected (patient with recent surgery on parathyroid) * (+) or (-) “Trousseaus” (contracture of forearm when B/P cuff is inflated on upper arm)
	2. “Homonymous Hemianopia” Loss of vision on one side in both visual fields (upper and lower) *Caused by a cerebral occlusion		#“Homonymous Hemianopia” Loss of vision on one side in both visual fields (upper and lower) *Caused by a cerebral occlusion
	3. “Asterixis” non-rhythmic flapping of wrists and hands with arms extended and wrists hyper-flexed (hepatic encephalopathy) (in alcoholic patients)		#“Asterixis” non-rhythmic flapping of wrists and hands with arms extended and wrists hyper-flexed (hepatic encephalopathy) (in alcoholic patients)
	Acute narrow angle closure glaucoma: dilated, non-reactive pupils, eye pain, decreased visual acuity, blurred vision, pressure over eye, corneal clouding, halos, nausea/vomiting.Caused by certain medications: (ie, sympathomimetics, anticholinergics, antidepressants [SSRIs], anticonvulsants, sulfonamides, cocaine, botulinum toxin),[10, 11, 12, 13, 14] dim light, and rapid correction of hyperglycemia. Trauma.		Acute narrow angle closure glaucoma: dilated, non-reactive pupils, eye pain, decreased visual acuity, blurred vision, pressure over eye, corneal clouding, halos, nausea/vomiting.Caused by certain medications: (ie, sympathomimetics, anticholinergics, antidepressants [SSRIs], anticonvulsants, sulfonamides, cocaine, botulinum toxin),[10, 11, 12, 13, 14] dim light, and rapid correction of hyperglycemia. Trauma.

Treloars: /* SYNCOPE/FAINTING */

2017-06-29T18:53:52Z

SYNCOPE/FAINTING

← Older revision		Revision as of 18:53, 29 June 2017
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	#How was patient moved to stretcher?		#How was patient moved to stretcher?

			==== TASER DEPLOYMENT ====
			#Location of probes
			# # of shots, # of shocks, duration of shocks
			#ETOH/Substance abuse involved?
			#Probes removed? (impaled?)
			#Trauma Assessment/other injuries?
	TASER DEPLOYMENT		#Blood loss?
	1. Location of probes		#Interventions by agency
	2. # of shots, # of shocks, duration of shocks		#Last Tetanus shot?
	3. ETOH/Substance abuse involved?
	4. Probes removed? (impaled?)
	5. Trauma Assessment/other injuries?
	6. Blood loss?
	7. Interventions by agency
	8. Last Tetanus shot?

	TRAUMA ALERT		TRAUMA ALERT

Treloars: /* SEIZURE */

2017-06-29T18:47:37Z

SEIZURE

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Treloars at 18:42, 29 June 2017

2017-06-29T18:42:59Z

← Older revision		Revision as of 18:42, 29 June 2017
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	#Interventions by agency?		#Interventions by agency?

	REFUSAL OF SERVICE		==== REFUSAL OF SERVICE ====
	1. Vital Signs		#Vital Signs
	2. Patient alert and oriented x4		#Patient alert and oriented x4
	3. GCS if applicable		#GCS if applicable
	4. Presence/Absence of Drugs/Alcohol?		#Presence/Absence of Drugs/Alcohol?
	5. Attempts at assessment/provision of care documented?		#Attempts at assessment/provision of care documented?
	6. Patient advised to seek care; risks/benefits explained?		#Patient advised to seek care; risks/benefits explained?
	7. Legal Guardian or POA if applicable		#Legal Guardian or POA if applicable
	8. Waiver Completed?		#Waiver Completed?
	9. Refusal Statement included		#Refusal Statement included

			==== RESPIRATORY DISTRESS or ARREST ====
			#Patient’s position
			#Anxiety level/Environment (if applicable)
			#Sudden or gradual onset?
			#Retractions?
			#Speech fragmentation?
			#JVD? At what position?
	RESPIRATORY DISTRESS or ARREST		#Trachea midline?
			#Angioedema? (ACE Inhibitors?)
	1. Patient’s position		#Pretibial edema (+ or -)
	2. Anxiety level/Environment (if applicable)		#Other edema (forehead, wrist, etc.)
	3. Sudden or gradual onset?		#Chest pain?
	4. Retractions?		#Nausea/vomiting?
	5. Speech fragmentation?		#Cap refill
	6. JVD? At what position?		#Conjunctiva
	7. Trachea midline?		#MM (tongue)
	8. Angioedema? (ACE Inhibitors?)		#Skin color/temp
	9. Pretibial edema (+ or -)		#Lung Sounds
	~~10.~~ Other edema (forehead, wrist, etc.)		#12 lead
	~~11.~~ Chest pain?		#Cough (productive?- describe) (hemoptysis?)
	~~12.~~ Nausea/vomiting?		#Recent immobility or surgery?
	~~13.~~ Cap refill		#Hx or current calf pain on standing or dorsiflexion ( (+) Homans sign)
	~~14.~~ Conjunctiva		#Dialysis Patient (last dialysis) (report card)
	~~15.~~ MM (tongue)		#Circumoral cyanosis?
	~~16.~~ Skin color/temp		#Pursed lips, accessory muscle use, nasal flaring?
	~~17.~~ Lung Sounds		#Fever?
	~~18.~~ 12 lead		#Night sweats?
	~~19.~~ Cough (productive?- describe) (hemoptysis?)		#Recent Travel Outside US, recent illness of family members?
	~~20.~~ Recent immobility or surgery?		#Finger Clubbing?
	~~21.~~ Hx or current calf pain on standing or dorsiflexion ( (+) Homans sign)		#Previous Intubations/Ventilator?
	~~22.~~ Dialysis Patient (last dialysis) (report card)		#Treatment prior to FD arrival
	~~23.~~ Circumoral cyanosis?		#Interventions by agency
	~~24.~~ Pursed lips, accessory muscle use, nasal flaring?		#How was patient moved to stretcher?
	~~25.~~ Fever?
	~~26.~~ Night sweats?
	~~27.~~ Recent Travel Outside US, recent illness of family members?
	~~28.~~ Finger Clubbing?
	~~29.~~ Previous Intubations/Ventilator?
	~~30.~~ Treatment prior to FD arrival
	~~31.~~ Interventions by agency
	~~32.~~ How was patient moved to stretcher?
	*See Intubation Benchmarks		*See Intubation Benchmarks

			==== SEIZURE ====
			#Hx of seizure? Same or different?
			#Description of seizure activity
			#Duration of seizure activity
			#Postictal?
			#Number of seizures
			#Head/Facial/Oral trauma?
			#Other injury?
	SEIZURE		#LOC
			#GCS
	1. Hx of seizure? Same or different?		#Pupils
	2. Description of seizure activity		#Fever?
	3. Duration of seizure activity		#Recent Illness? (Travel outside US or visitors/family illness)
	4. Postictal?		#H/A?
	5. Number of seizures		#Rash?
	6. Head/Facial/Oral trauma?		#Nuccal Rigidity? Or Supple?
	7. Other injury?		#Incontinence (bowel or bladder)?
	8. LOC		#ETOH/Substance involvement?
	9. GCS		#BGL
	~~10.~~ Pupils		#(+) Trousseau?
	~~11.~~ Fever?		#Dialysis Patient? Last Dialysis? Report Card
	~~12.~~ Recent Illness? (Travel outside US or visitors/family illness)		#Cardiac Arrythmia? (EKG)
	~~13.~~ H/A?		#Interventions by agency
	~~14.~~ Rash?		#How was patient moved to stretcher?
	~~15.~~ Nuccal Rigidity? Or Supple?
	~~16.~~ Incontinence (bowel or bladder)?
	~~17.~~ ETOH/Substance involvement?
	~~18.~~ BGL
	~~19.~~ (+) Trousseau?
	~~20.~~ Dialysis Patient? Last Dialysis? Report Card
	~~21.~~ Cardiac Arrythmia? (EKG)
	~~22.~~ Interventions by agency
	~~23.~~ How was patient moved to stretcher?

	SEXUAL ASSAULT/RAPE		SEXUAL ASSAULT/RAPE

Treloars at 18:39, 29 June 2017

2017-06-29T18:39:29Z

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