Documentation
Topics Principles and Purposes of
EMS Documentation Medical Terminology & Abbreviations Roles of Documentation Subjective & Objective
Documentation Evaluation of a Finished Document Special Situations
Introduction
Your written prehospital carereport (PCR) is the only truefactual record of events.
Your PCR is your solepermanent, complete writtenrecord of events during theambulance call.
Uses for PCR’s
Medical Administrative Research Legal
Run data in a PCR helps agencies to improve patient care.
Complete both the narrative and check-box sections of every PCR.
General Considerations
Use appropriate medicalterminology.
Use acceptable and approvedabbreviations and acronyms.
If you do not know how to spell a word, look it up or use another word…
Some systems use check boxes, some use bubble-sheets, and others use
electronic documentation
Times
Whenever possible, record alltimes from the same clock.
When that is not possible, besure that all the clocks andwatches you use aresynchronized.
Communications
The communications with thehospital are another important item to document.
Document ANY medical advice ororders you receive and the results of implementing that advice and those orders.
Pertinent Negatives
Document all findings of your assessment, even those that are normal.
Oral Statements
Whenever possible, quote the patient—or other source of information—directly.
Example: Bystanders state the patient was “acting bizarre and threatening to jump in front of the next passing car.”
Elements of Good Documentation
Accuracy Legibility Timeliness Absence of alterations Professionalism
The Proper Way to Correct a Prehospital Care Report
Professionalism
Never include slang, biasedstatements, or irrelevantopinions.
Include only objectiveinformation.
Always write and speak clearly.
2 Narrative Formats
CHART Chief complaint History Assessment Rx (treatment) Transport
SOAP Subjective Objective Assessment Plan
Narrative Writing
Subjective part of your narrativecomprises any information that youelicit during your patient’s history.
Objective part of your narrativeusually includes your generalimpression and any data that youderive through inspection, palpation, auscultation, percussion, anddiagnostic testing.
Special Considerations
Patient refusals Services not needed Mass casualty incidents
Patient Refusals
Patients retain the right to refusetreatment or transportation if theyare competent to make that decision.
Two main types of refusals: Person who is not seriously
injured and does not want to go to the hospital
The patient refuses even though you feel he needs it.
A patient’s refusal of care requires careful documentation.
One Example of a “Refusal of Care” Form
Services Not Needed
Some systems allow paramedics todetermine patients that do notrequire ambulance transportation.
While this may help to reduceambulance utilization, the risks ofdenying transport are even greaterthan those of a refusal.
Evaluate all patients with even minor injuries and document appropriately.
Mass Casualty Incidents
Multiple patients, mass casualties,and disasters all present specialdocumentation problems.
Weigh your patient’s needs againstthe demand for completedocumentation.
Follow local guidelines and utilizethe appropriate forms such as triage tags.
Triage tags are used to record vital information on each patient quickly.
Consequences of Inappropriate
Documentation Inappropriate documentation can
have both medical and legalconsequences. Do not guess about your patient’s
problems. Write neatly, clearly, and legibly. Complete your form completely. Spelling counts!
Summary Principles and Purposes of
EMS Documentation Medical Terminology & Abbreviations Roles of Documentation Subjective & Objective
Documentation Evaluation of a Finished Document Special Situations