14.3 Documentation and handover procedures

Accurate documentation and effective handover procedures are crucial in first aid and patient care. They ensure continuity of care, protect patient privacy, and provide legal records. Proper documentation includes patient care reports, incident details, and SOAP notes, while handovers use techniques like ISBAR for clear communication.

Confidentiality and legal considerations are paramount in healthcare documentation. Providers must maintain patient privacy, follow chain of custody procedures for evidence, and create thorough, accurate records to mitigate legal risks and demonstrate compliance with professional standards.

Documentation

Patient Care Reports and Documentation

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• Patient care reports (PCRs) document all aspects of patient care from initial assessment to final disposition
  • Includes patient demographics, chief complaint, history, physical exam findings, vital signs, interventions, and outcomes
  • Serves as a legal record of care provided and aids in continuity of care
• Incident documentation records details of the emergency incident
  • Encompasses scene assessment, hazards, resources utilized, and actions taken
  • Provides a comprehensive account of the event for legal, quality improvement, and debriefing purposes
• Electronic health records (EHRs) store and transmit patient information digitally
  • Facilitates data sharing among healthcare providers and institutions
  • Enhances accessibility, legibility, and security of patient records compared to paper-based systems

SOAP Notes

• SOAP notes are a standardized format for documenting patient encounters
  • Subjective: Patient's reported symptoms, concerns, and relevant history
  • Objective: Measurable findings such as vital signs, physical exam results, and diagnostic tests
  • Assessment: Provider's diagnosis or impression based on subjective and objective data
  • Plan: Recommended treatment, interventions, referrals, and follow-up
• Organizes information in a clear, concise manner for effective communication and decision-making
• Commonly used in various healthcare settings (primary care, emergency departments, rehabilitation)

Legal and Ethical Considerations

Confidentiality and Chain of Custody

• Confidentiality ensures patient privacy by protecting sensitive health information from unauthorized disclosure
  • Governed by laws and regulations (HIPAA in the United States, Data Protection Act in the United Kingdom)
  • Requires secure storage, transmission, and access controls for patient records
• Chain of custody tracks the movement and handling of evidence from collection to presentation in legal proceedings
  • Maintains integrity and credibility of evidence by documenting each transfer of custody
  • Crucial in cases involving criminal investigations or legal disputes related to patient care

Legal Considerations

• Documentation must be accurate, complete, and timely to mitigate legal risks
  • Inconsistencies or omissions can lead to questions about the quality of care provided
  • Thorough documentation supports defense against malpractice claims or disciplinary actions
• Providers must adhere to scope of practice, professional standards, and institutional policies
  • Deviations from established protocols may constitute negligence or misconduct
  • Proper documentation demonstrates compliance with legal and ethical obligations

Handover Procedures

ISBAR Handover Technique

• ISBAR is a structured communication tool for effective handovers between healthcare professionals
  • Identify: Introduce yourself, your role, and the patient being discussed
  • Situation: Briefly state the current situation and reason for the handover
  • Background: Provide relevant medical history, treatment, and progress to date
  • Assessment: Share your clinical impression, concerns, and potential risks
  • Recommendation: Propose a plan of action, including pending tasks and contingencies
• Ensures critical information is conveyed clearly and concisely during transitions of care
  • Minimizes omissions, misunderstandings, and delays in treatment
  • Particularly valuable in time-sensitive situations (shift changes, transfers between units or facilities)