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RECORDS & REPORTS EMERGENCY MEDICAL TECHNICIAN - BASIC PURPOSE OF DOCUMENTATION Continuity of patient care Regulatory requirements Quality assurance Research Justification of treatment Protection for personnel Administration A GOOD MEDICAL RECORD IS.. Accurate

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RECORDS & REPORTS

EMERGENCY MEDICAL TECHNICIAN - BASIC

Temple College EMS Professions


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PURPOSE OF DOCUMENTATION

  • 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 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


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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


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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


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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


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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


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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


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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


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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


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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


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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


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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


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PATIENT REFUSAL

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

Temple College EMS Professions


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