RECORDS & REPORTS

1. RECORDS & REPORTS EMERGENCY MEDICAL TECHNICIAN - BASIC

2. PURPOSE OF DOCUMENTATION • Continuity of patient care • Regulatory requirements • Quality assurance • Research • Justification of treatment • Protection for personnel • Administration

3. A GOOD MEDICAL RECORD IS.. • Accurate • Document facts and observations ONLY • Double-check numerical entries • Recheck spellings • If you make an error, DOCUMENT IT

4. 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?

5. 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

6. 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”

7. 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

8. 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

9. 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

10. 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!

11. DOCUMENTATION • If you have a prolonged scene time, say why • If times are to be documented on your report, do so accurately!

12. 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

13. 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

14. PATIENT REFUSAL • If the Pt. will not sign, have the document signed by family, law enforcement, or bystander