Temple College EMS Professions
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RECORDS & REPORTS
EMERGENCY MEDICALTECHNICIAN - BASIC
Temple College EMS Professions
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PURPOSE OFDOCUMENTATION
•Continuity of patient care
•Regulatory requirements
•Quality assurance
•Research
•Justification of treatment
•Protection for personnel
•Administration
Temple College EMS Professions
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A GOOD MEDICAL RECORDIS..
•Accurate
–Document facts and observations ONLY
–Double-check numerical entries
–Recheck spellings
–If you make an error, DOCUMENT IT
Temple College EMS Professions
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A GOOD MEDICAL RECORDIS..
•Complete
–The lines are there to fill in
–Include at least two sets of vitals on everypatient
–Failure to document = failure to investigatealways document pertinent negatives
–If it wasn’t documented, it wasn’t done
–Can you remember what you did two years agotoday?
Temple College EMS Professions
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A GOOD MEDICAL RECORDIS..
•Legible
–Documents presented in court must “speak forthemselves”
–Sloppy report = sloppy care
–Recheck spellings
–If the document cannot be deciphered, a jurymay ignore it altogether
Temple College EMS Professions
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A GOOD MEDICAL RECORDIS..
•Free of extraneous information
–Avoid labeling patient. Report observations.
–Preface statements “per the witness” or “per thepatient”
–Record hearsay only if applicable
–Do not record hearsay as fact
–Avoid humor in the report. The public does notregard EMS as “funny business”
Temple College EMS Professions
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DOCUMENTATION
•Good documentation reflects good patientcare!
•Write report as soon after run as possible!
•If it needs to be corrected, correct t!
–The earlier the correction, the more reliable thechange
–Mark through error so it is still legible, thenmake correction and initial it
Temple College EMS Professions
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DOCUMENTATION
•If you have a long report, don’t hesitate toadd additional pages
•Avoid stating diagnostic impressions
–Report only facts and observations
–If you must state a diagnostic impression, do sowithin your scope of training
Temple College EMS Professions
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DOCUMENTATION
•Avoid using “Possible” or “?” when theobservation would have been obvious toanyone
•If you do something to the patient, say whatyou did, why you did it, when you did it,and what the result was
Temple College EMS Professions
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DOCUMENTATION
•If you state a particular diagnosticimpression, or note a particular mechanismof injury, be sure the treatment you indicateis appropriate
•If something should have been done, butwas not, say why!
Temple College EMS Professions
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DOCUMENTATION
•If you have a prolonged scene time, saywhy
•If times are to be documented on yourreport, do so accurately!
Temple College EMS Professions
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PATIENT REFUSAL
•Perform Pt. assessment (If Pt. will allow)
•Try to persuade the Patient to accepttreatment and transport (if indicated)
•Explain consequences of refusingtreatment/transport
Temple College EMS Professions
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PATIENT REFUSAL
•If the Pt. still refuses treatment - Document:
–Pt. Decision
–your assessment
–any attempts made to convince Pt. to accepttreatment and transport
•Document Pt. refusal and obtain Pt.Signature
Temple College EMS Professions
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PATIENT REFUSAL
•If the Pt. will not sign, have the documentsigned by family, law enforcement, orbystander