REFERENCE Quality Improvement Document Criteria Documentation on all patients must include the following and any other information pertinent to patient care: OPQRST and SAMPLE are the acronyms for the United States DOT EMS and Paramedic patient assessment curriculum O Circumstance surroundings on the onset of S Signs, symptoms, physical exam findings – – complaint A Allergies to medications or the environment – P What provoked (or provokes) the complaint? M Medications, prescription or over the counter – – Environment P Past medical history – Q Describe the quality (sharp, burning, stabbing L Last oral intake – – counter etc.)of the complaint? E Event, what happened to the patient – R does the pain radiate? – S Describe the severity of the pain on a 1-10 – scale 1 (minimal) 10 (maximum) – T Time of onset? – All patients transported by EMS should have at two sets of vital signs assessed and documented. Initial set of vitals will include blood pressure (systolic/diastolic), pulse rate, respiratory rate, pulse oximetry and blood glucose if indicated, and the time they were assessed must be recorded. All medications taken by the patient should be listed on the report. If medications are taken to ER document in narrative who the medications were left with. When documenting the presumed presence of alcohol that is based solely upon breath odor, do so in the following manner: breath has the odor that is commonly associated with the “Patient’s consumption of alcohol.” ABDOMINAL PAIN/PROBLEMS ALCOHOL INTOXICATION Location of pain Patient’s breath has odor of ETOH Distension Patient admits to drinking (type, amount, Tenderness/radiation time frame) Nausea/Vomiting/Diarrhea Speech (normal, slurred) Urinary complaints Gait (normal, unsteady) LMP if applicable Any obvious injuries Vaginal bleeding/discharge if applicable Blood glucose level Treatment/reassessments of consciousness Report and signature of RN Treatment/reassessments Report given and signature of RN ALTERED MENTAL STATUS ASSAULT/FIGHT OPQRST, SAMPLE as appropriate OPQRST, SAMPLE as appropriate ETOH/Substance use Method of assault Any obvious injuries noted Any obvious injuries or pain Blood glucose level Loss of consciousness, how long Normal mental status Treatment/reassessments EKG and strip attached Report given and signature of RN Treatment/reassessments Report given and signature of RN
REFERENCE Quality Improvement Document Criteria Documentation on all patients must include the following and any other information pertinent to patient care: OPQRST and SAMPLE are the acronyms for the United States DOT EMS and Paramedic patient assessment curriculum O – Circumstance surroundings on the onset of complaint P – What provoked (or provokes) the complaint? Environment Q – Describe the quality (sharp, burning, stabbing counter etc.)of the complaint? R – does the pain radiate? S – Describe the severity of the pain on a 1-10 scale 1 (minimal) – 10 (maximum) T – Time of onset? S – Signs, symptoms, physical exam findings A – Allergies to medications or the environment M – Medications, prescription or over the counter P – Past medical history L – Last oral intake E – Event, what happened to the patient All patients transported by EMS should have at two sets of vital signs assessed and documented. Initial set of vitals will include blood pressure (systolic/diastolic), pulse rate, respiratory rate, pulse oximetry and blood glucose if indicated, and the time they were assessed must be recorded. All medications taken by the patient should be listed on the report. If medications are taken to ER document in narrative who the medications were left with. When documenting the presumed presence of alcohol that is based solely upon breath odor, do so in the following manner: “Patient’s breath has the odor that is commonly associated with the consumption of alcohol.” ABDOMINAL PAIN/PROBLEMS Location of pain Distension Tenderness/radiation Nausea/Vomiting/Diarrhea Urinary complaints LMP if applicable Vaginal bleeding/discharge if applicable Treatment/reassessments Report and signature of RN ALCOHOL INTOXICATION Patient’s breath has odor of ETOH Patient admits to drinking (type, amount, time frame) Speech (normal, slurred) Gait (normal, unsteady) Any obvious injuries Blood glucose level of consciousness Treatment/reassessments Report given and signature of RN ALTERED MENTAL STATUS OPQRST, SAMPLE as appropriate ETOH/Substance use Any obvious injuries noted Blood glucose level Normal mental status EKG and strip attached Treatment/reassessments Report given and signature of RN ASSAULT/FIGHT OPQRST, SAMPLE as appropriate Method of assault Any obvious injuries or pain Loss of consciousness, how long Treatment/reassessments Report given and signature of RN
Tennessee-Guideline-07282016.docx