1. Documentation

2. Topics
 Principles and Purposes of
EMS Documentation
 Medical Terminology & Abbreviations
 Roles of Documentation
 Subjective & Objective
Documentation
 Evaluation of a Finished Document
 Special Situations

3. Introduction
 Your written prehospital care
report (PCR) is the only true
factual record of events.
 Your PCR is your sole
permanent, complete written
record of events during the
ambulance call.

4. Uses for PCR’s
 Medical
 Administrative
 Research
 Legal

5. Run data in a PCR helps agencies to
improve patient care.

6. Complete both the narrative and
check-box sections of every PCR.

7. General Considerations
 Use appropriate medical
terminology.
 Use acceptable and approved
abbreviations and acronyms.
If you do not know how to spell
a word, look it up or use
another word…

8. Some systems use check boxes, some
use bubble-sheets, and others use
electronic documentation

9. Times
 Whenever possible, record all
times from the same clock.
 When that is not possible, be
sure that all the clocks and
watches you use are
synchronized.

10. Communications
 The communications with the
hospital are another important
item to document.
 Document ANY medical advice or
orders you receive and the results
of implementing that advice and
those orders.

11. Pertinent Negatives
 Document all findings of your
assessment, even those that
are normal.

12. Oral Statements
 Whenever possible, quote the
patient—or other source of
information—directly.
Example: Bystanders state the
patient was “acting bizarre and
threatening to jump in front of
the next passing car.”

13. Elements of Good Documentation
 Accuracy
 Legibility
 Timeliness
 Absence of alterations
 Professionalism

14. The Proper Way to Correct a
Prehospital Care Report

15. Professionalism
 Never include slang, biased
statements, or irrelevant
opinions.
 Include only objective
information.
 Always write and speak clearly.

16. 2 Narrative Formats
CHART SOAP
 Chief complaint  Subjective
 History  Objective
 Assessment  Assessment
 Rx (treatment)  Plan
 Transport

17. Narrative Writing
 Subjective part of your narrative
comprises any information that you
elicit during your patient’s history.
 Objective part of your narrative
usually includes your general
impression and any data that you
derive through inspection,
palpation, auscultation, percussion,
and
diagnostic testing.

18. Special Considerations
 Patient refusals
 Services not needed
 Mass casualty incidents

19. Patient Refusals
 Patients retain the right to refuse
treatment or transportation if they
are competent to make that
decision.
 Two main types of refusals:
 Person who is not seriously
injured and does not want to go to
the hospital
 The patient refuses even though
you feel he needs it.

20. A patient’s refusal of care requires
careful documentation.

21. One Example of a
“Refusal of Care” Form

22. Services Not Needed
 Some systems allow paramedics to
determine patients that do not
require ambulance transportation.
 While this may help to reduce
ambulance utilization, the risks of
denying transport are even greater
than those of a refusal.
 Evaluate all patients with even
minor injuries and document
appropriately.

23. Mass Casualty Incidents
 Multiple patients, mass casualties,
and disasters all present special
documentation problems.
 Weigh your patient’s needs against
the demand for complete
documentation.
 Follow local guidelines and utilize
the appropriate forms such as
triage tags.

24. Triage tags are used to record vital
information on each patient quickly.

25. Consequences of
Inappropriate Documentation
 Inappropriate documentation can
have both medical and legal
consequences.
 Do not guess about your patient’s
problems.
 Write neatly, clearly, and legibly.
 Complete your form completely.
 Spelling counts!

26. Summary
 Principles and Purposes of
EMS Documentation
 Medical Terminology & Abbreviations
 Roles of Documentation
 Subjective & Objective
Documentation
 Evaluation of a Finished Document
 Special Situations