Report Writing (Powerpoint) - Volusia County Fire Chiefs` Association
Report Writing
EMS and Fire Reports
Why do we write reports?
• Medical documentation
• Administrative information
• Research
• Legal
– Attorneys will have access to YOUR report in a legal preceding
Patient Care Reports
• A well written PCR is accurate, legible, timely, unaltered and professional.
• Volusia County Protocols require a PCR be completed to include the data in a SOAPP format.
SOAPP FORMAT
• Subjective
– Chief Complaint
– History of present illness (including history of events surrounding the call)
– Past medical history
SOAPP FORMAT
• Objective
– Vital signs
(normal/abnormal)
– General impression/ physical findings
(normal/abnormal in relation to the chief complaint)
SOAPP FORMAT
• Assessment
– Working diagnosis and it can be the same as the chief complaint.
SOAPP FORMAT
• Plan
– Protocol(s) followed
• Intubations (all airways),
IV’s, I/O’s need to document number of attempts
– Physicians orders
• Include the name of the physician giving the order.
SOAPP FORMAT
• Prehospital Course
– Assessment / management performed and how did the patient respond.
– This may be short if patient care is transferred quickly
Reports
• Cardiac Alerts / Stroke alerts
/Trauma Alert criteria sheets will need to be attached to the hard copy PCR.
– Additionally, the new Cardiac
Alert protocols will address
STEMI alerts (ST elevation in an
MI)
• Patient refusals need to documented and the PCR forwarded to administration.
PCR - Refusals
• Refusals shall receive complete documentation on the hard copy.
– Refusal witness shall be from another agency (i.e.
LEO, EVAC)
• Electronic reports for refusal shall be in the
SOAPP context .
PCR - Refusals
• Documentation should include the following:
– Thorough assessment
– Patient competency (alert & oriented x
4)
– Your recommendation for care and transport
– Explanation you gave to the patient in reference to consequences of refusing up to and including death
– Patient’s understanding of your statements
– Advising patient you will return if they change their mind
PCR – EVAC assists
• PCR shall include the following:
– What you were dispatched to .
– What you found upon arrival. (EVAC conducting pt. assessment / pt. loaded for transport / Care assistance provided)
– Prehospital course your unit provided.
PCR – Patient Assists
• What your unit was dispatched to.
• What you found upon arrival.
• What course of action you took (vitals, assist to bed, ect.)
PCR – Cancelled Prior to Arrival
• Dispatch information
• Reason for cancellation
– Time of cancellation, who cancelled your agency.
Documentation
• Just hitting the autogenerate button on
Firehouse does not complete your report responsibilities.
• Remember that poor, incomplete or inaccurate documentation can be costly in a lawsuit both to you and your agency.
Fire Reports
• Like a PCR, proper documentation of all dispatched calls is an essential requirement of your job.
Required NIFRS Information
• Location
• Date
• Times
• Apparatus /
Personnel responding
• Incident type
• Property type
• Resident /
Owner
• Level / area of origin
• Information about the structure and presence of protection systems
• Damage / loss information
Narrative
• Dispatch information
– Turnout times greater than 60 sec. will require documentation in NIFRS
• Causes can include in training/ apparatus checks/pre-plans & inspection/ immediately enroute time inaccurate, ect.
– Delays will require documentation in NIFRS
• Traffic / wrong address / train / security gates, ect.
• Any time greater than a 30 sec. delay will be documented.
Narrative
• Arrival / Size-up information
• Command
• Assignments
– Mode, Attack, Water supply, Utilities, Search,
RIT, Ventilation, Rehab, ect.
Narrative
• Thermal Imager use
• Special or unusual actions including deviating from SOP’s
• Injuries or death (in addition, complete the appropriate NFIRS)
• Investigation results (note when the Fire Marshal or PD is investigating further)
• Any damaged or broken equipment (may be an addendum)
Narrative – False Alarms
• Dispatch information
• Arrival information
• Disposition (what you found)
• Facility member or homeowner you made contact with to confirm the false alarm.
Narrative – Cancelled Enroute
• Dispatch Information
• Reason for cancellation
• Name of the person who cancelled the Fire
Department
Practical Assignments
• Using the SOAPP method complete a written PCR narrative for the EMS information given.
• Complete a narrative for the information given for a fire report.
References
• Volusia County Medical
Protocols
• Bledsoe, Cherry, Porter
(2003), Essentials of
Paramedic Care, Brady;
Upper saddle River, NJ
• IFSTA (2001), Fire
Department Company
Officer; Third Edition,
Stillwater, OK.
