Records and Reports

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