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Report Writing

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.

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Report Writing

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  1. Report Writing EMS and Fire Reports

  2. Why do we write reports? • Medical documentation • Administrative information • Research • Legal • Attorneys will have access to YOUR report in a legal preceding

  3. 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.

  4. SOAPP FORMAT • Subjective • Chief Complaint • History of present illness (including history of events surrounding the call) • Past medical history

  5. SOAPP FORMAT • Objective • Vital signs (normal/abnormal) • General impression/ physical findings (normal/abnormal in relation to the chief complaint)

  6. SOAPP FORMAT • Assessment • Working diagnosis and it can be the same as the chief complaint.

  7. 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.

  8. SOAPP FORMAT • Prehospital Course • Assessment / management performed and how did the patient respond. • This may be short if patient care is transferred quickly

  9. 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.

  10. 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 .

  11. 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

  12. 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.

  13. 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.)

  14. PCR – Cancelled Prior to Arrival • Dispatch information • Reason for cancellation • Time of cancellation, who cancelled your agency.

  15. Documentation • Just hitting the auto-generate 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.

  16. Fire Reports • Like a PCR, proper documentation of all dispatched calls is an essential requirement of your job.

  17. 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 Required NIFRS Information

  18. 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.

  19. Narrative • Arrival / Size-up information • Command • Assignments • Mode, Attack, Water supply, Utilities, Search, RIT, Ventilation, Rehab, ect.

  20. 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)

  21. Narrative – False Alarms • Dispatch information • Arrival information • Disposition (what you found) • Facility member or homeowner you made contact with to confirm the false alarm.

  22. Narrative – Cancelled Enroute • Dispatch Information • Reason for cancellation • Name of the person who cancelled the Fire Department

  23. 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.

  24. 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.

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