RECORDS & REPORTS
EMERGENCY MEDICAL TECHNICIAN
- BASIC
Temple College EMS Professions
1
PURPOSE OF
DOCUMENTATION
•
•
•
•
•
•
•
Continuity of patient care
Regulatory requirements
Quality assurance
Research
Justification of treatment
Protection for personnel
Administration
Temple College EMS Professions
2
A GOOD MEDICAL RECORD
IS..
• Accurate
–
–
–
–
Document facts and observations ONLY
Double-check numerical entries
Recheck spellings
If you make an error, DOCUMENT IT
Temple College EMS Professions
3
A GOOD MEDICAL RECORD
IS..
• Complete
– The lines are there to fill in
– Include at least two sets of vitals on every
patient
– Failure to document = failure to investigate
always document pertinent negatives
– If it wasn’t documented, it wasn’t done
– Can you remember what you did two years ago
today?
Temple College EMS Professions
4
A GOOD MEDICAL RECORD
IS..
• Legible
– Documents presented in court must “speak for
themselves”
– Sloppy report = sloppy care
– Recheck spellings
– If the document cannot be deciphered, a jury
may ignore it altogether
Temple College EMS Professions
5
A GOOD MEDICAL RECORD
IS..
• Free of extraneous information
– Avoid labeling patient. Report observations.
– Preface statements “per the witness” or “per the
patient”
– Record hearsay only if applicable
– Do not record hearsay as fact
– Avoid humor in the report. The public does not
regard EMS as “funny business”
Temple College EMS Professions
6
DOCUMENTATION
• Good documentation reflects good patient
care!
• Write report as soon after run as possible!
• If it needs to be corrected, correct t!
– The earlier the correction, the more reliable the
change
– Mark through error so it is still legible, then
make correction and initial it
Temple College EMS Professions
7
DOCUMENTATION
• If you have a long report, don’t hesitate to
add additional pages
• Avoid stating diagnostic impressions
– Report only facts and observations
– If you must state a diagnostic impression, do so
within your scope of training
Temple College EMS Professions
8
DOCUMENTATION
• Avoid using “Possible” or “?” when the
observation would have been obvious to
anyone
• If you do something to the patient, say what
you did, why you did it, when you did it,
and what the result was
Temple College EMS Professions
9
DOCUMENTATION
• If you state a particular diagnostic
impression, or note a particular mechanism
of injury, be sure the treatment you indicate
is appropriate
• If something should have been done, but
was not, say why!
Temple College EMS Professions
10
DOCUMENTATION
• If you have a prolonged scene time, say
why
• If times are to be documented on your
report, do so accurately!
Temple College EMS Professions
11
PATIENT REFUSAL
• Perform Pt. assessment (If Pt. will allow)
• Try to persuade the Patient to accept
treatment and transport (if indicated)
• Explain consequences of refusing
treatment/transport
Temple College EMS Professions
12
PATIENT REFUSAL
• If the Pt. still refuses treatment - Document:
– Pt. Decision
– your assessment
– any attempts made to convince Pt. to accept
treatment and transport
• Document Pt. refusal and obtain Pt.
Signature
Temple College EMS Professions
13
PATIENT REFUSAL
• If the Pt. will not sign, have the document
signed by family, law enforcement, or
bystander
Temple College EMS Professions
14