Guideline 1-800-33 - Clinical Reviews

CMH EMS & MIH Protocols

Scope

Guideline:

Purpose:

Procedure:

Refer to Guideline 1-450-33 - Documentation Reviewer Reference Sheet.

Refer to Guideline 1-700-33 - Documenter Reference Sheet for reference and definitions.

Refer to Guideline 1-800 - Quality Improvement to determine which charts should be reviewed.

Reviewers should look for:

• All charts:
• In general, if there is a fill-in spot or drop-down for something, it should be documented there, not the narrative.
• Review the appropriate protocol and determine minimum treatments were provided.
• Review the narrative. Were all parts of DRATT included?
• Trauma:
• C-collar and SMR applied according to Protocol 2-836 - Spinal Immobilization Clearance?
• Appropriate vascular access?
• Oxygen administered appropriately?
• TXA administered, if appropriate?
• Was the patient warmed?
• Scene time and landing zone time kept to a minimum?
• Transported according to Protocol 2-924 - Universal Patient Care?
• RSI or airway needed:
• Treated according to Protocol 2-044 - Airway: RSI?
• Was RSI appropriate? Was RSI needed and not provided?
• Medications given correctly?
• Attempts, placement, confirmation, etc. documented?
• Sepsis:
• Treated according to Protocol 2-440 - Fever / Sepsis?
• Temperature recorded?
• Capnography recorded?
• Source of infection investigated?
• LR fluid bolus appropriately given?
• Blood sugar checked and managed appropriately?
• Scene time and landing zone time kept to a minimum?
• Transported appropriately?
• STEMI:
• Treated according to Protocol 2-220 - Chest Pain / Suspected Cardiac Event?
• Aspirin within time goal?
• 12-lead within time goal?
• Scene time and landing zone time kept to a minimum?
• Transported according to Protocol 2-220 - Chest Pain / Suspected Cardiac Event?
• Stroke:
• Treated according to Protocl 2-880 - Suspected Stroke?
• Blood sugar checked?
• NIHSS completed?
• Last known well time documented?
• Scene time and landing zone time kept to a minimum?
• Transported according to Protocl 2-880 - Suspected Stroke?

Add feedback:

• Be specific, positive, and give them the benefit of the doubt.

Rating:

Send message:

• Send message for review by the documenter: Include their manager as a recipient of the message. Consider adding their partner, too.
• If "Poor" rating is given, include Clinical Chief as a message recipient. Refer to Guideline 1-800-66 - Employee Remediation.

Change status:

• Mark "CLOSED."

CMH Pre-Hospital Services Mission: "Provide safe, exceptional, and compassionate care to our communities with an emphasis on highly trained and empowered staff."

CMH Mobile Integrated Healthcare Mission: "Provide exceptional, compassionate, and patient-centered care by a mobile collaborative team to improve patient experience, improve quality outcomes, and reduce healthcare costs."

Polk, Hickory, Cedar, & St Clair County EMS Protocols is licensed under a Creative Commons Attribution-ShareAlike 4.0 International License.