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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

RECORDS & REPORTS

EMERGENCY MEDICAL TECHNICIAN - BASIC

Temple College EMS Professions

purpose of documentation
PURPOSE OF DOCUMENTATION
  • Continuity of patient care
  • Regulatory requirements
  • Quality assurance
  • Research
  • Justification of treatment
  • Protection for personnel
  • Administration

Temple College EMS Professions

a good medical record is
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

a good medical record is4
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

a good medical record is5
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

a good medical record is6
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

documentation
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

documentation8
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

documentation9
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

documentation10
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

documentation11
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

patient refusal
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

patient refusal13
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

patient refusal14
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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