REPORT WRITING TECHNIQUES When writing an ambulance report, be: Professional. Maintain consistency in report writing. Make sure that your report writing is legible, spelling is correct, and sentences make sense. Use medical terminology that you are familiar with. Contemporaneous. After you have completed your report it is acceptable to add an addendum to your report but this must be done on a different addendum form or incident form. Never change a run report that has been completed where a copy has been left at the hospital or in somebody else's hands. This takes credibility away from your run report. Additionally, for issues that are not medically related, such as response problems, mechanical problems, etc. use an incident report. Make sure to check with your provider for additional policy information. Accurate. Ensure that your times are accurate and that you simply tell the truth. Do not expand on areas that do not need to be expanded upon. And make sure you are presenting facts in your run report. Consistent. First of all, if you have an item that is in a box that has already been checked, it does not need to be duplicated in the narrative. If you do choose to duplicate an item or expand on an issue, make sure that the information provided in the box matches that in the narrative. Vital signs should match if they are duplicated or are copied from a scratch sheet if that is kept with the final run document. Thorough. If the patient is experiencing a sign or symptom that would normally require a specific treatment and you do not provide that treatment, be sure to document the rationale for not providing the treatment (e.g., "Nitroglycerine was not given for relief of the patient's chest pain because the patient had taken Viagra within the last 24 hours.") Clear. The most important thing to remember regarding your ambulance report is, could a third person with equal training be able to read the run report and reconstruct the run. If you can answer, "yes" to this question, you have presented a clear and concise report. Brief. Include relevant and significant information only. If there is a pertinent negative to report, then report it. Use caution, though, in reporting non-pertinent negatives (e.g., if the patient is having chest pain, is it important to document that the patient also has arthritis in the knee?). Avoid social comments. Illustrative. Paint a picture of what is going on with the patient. Remember, others must read your report and be able to understand what picture you are trying to paint. Collaborative. Remember, you and your partner are both responsible for what is written in your report. It is your service's choice whether your partner must actually sign your report; however, your partner should always review your report for its content. If your partner disagrees with what is written in the run report, an addendum can be attached to the run report. Objective. Your run report is not the place to voice opinions on the values or judgments of the patient you are treating or transporting. Use politically correct terminology.
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