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Report Writing. EMS and Fire Reports. Why do we write reports?. Medical documentation Administrative information Research Legal Attorneys will have access to YOUR report in a legal preceding. Patient Care Reports.

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Report Writing

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Report writing

Report Writing

EMS and Fire Reports


Why do we write reports

Why do we write reports?

  • Medical documentation

  • Administrative information

  • Research

  • Legal

    • Attorneys will have access to YOUR report in a legal preceding


Patient care reports

Patient Care Reports

  • A well written PCR is accurate, legible, timely, unaltered and professional.

  • Volusia County Protocols require a PCR be completed to include the data in a SOAPP format.


Soapp format

SOAPP FORMAT

  • Subjective

    • Chief Complaint

    • History of present illness (including history of events surrounding the call)

    • Past medical history


Soapp format1

SOAPP FORMAT

  • Objective

    • Vital signs (normal/abnormal)

    • General impression/ physical findings (normal/abnormal in relation to the chief complaint)


Soapp format2

SOAPP FORMAT

  • Assessment

    • Working diagnosis and it can be the same as the chief complaint.


Soapp format3

SOAPP FORMAT

  • Plan

    • Protocol(s) followed

      • Intubations (all airways), IV’s, I/O’s need to document number of attempts

    • Physicians orders

      • Include the name of the physician giving the order.


Soapp format4

SOAPP FORMAT

  • Prehospital Course

    • Assessment / management performed and how did the patient respond.

    • This may be short if patient care is transferred quickly


Reports

Reports

  • Cardiac Alerts / Stroke alerts /Trauma Alert criteria sheets will need to be attached to the hard copy PCR.

    • Additionally, the new Cardiac Alert protocols will address STEMI alerts (ST elevation in an MI)

  • Patient refusals need to documented and the PCR forwarded to administration.


Pcr refusals

PCR - Refusals

  • Refusals shall receive complete documentation on the hard copy.

    • Refusal witness shall be from another agency (i.e. LEO, EVAC)

  • Electronic reports for refusal shall be in the SOAPP context .


Pcr refusals1

PCR - Refusals

  • Documentation should include the following:

    • Thorough assessment

    • Patient competency (alert & oriented x 4)

    • Your recommendation for care and transport

    • Explanation you gave to the patient in reference to consequences of refusing up to and including death

    • Patient’s understanding of your statements

    • Advising patient you will return if they change their mind


Pcr evac assists

PCR – EVAC assists

  • PCR shall include the following:

    • What you were dispatched to .

    • What you found upon arrival. (EVAC conducting pt. assessment / pt. loaded for transport / Care assistance provided)

    • Prehospital course your unit provided.


Pcr patient assists

PCR – Patient Assists

  • What your unit was dispatched to.

  • What you found upon arrival.

  • What course of action you took (vitals, assist to bed, ect.)


Pcr cancelled prior to arrival

PCR – Cancelled Prior to Arrival

  • Dispatch information

  • Reason for cancellation

    • Time of cancellation, who cancelled your agency.


Documentation

Documentation

  • Just hitting the auto-generate button on Firehouse does not complete your report responsibilities.

  • Remember that poor, incomplete or inaccurate documentation can be costly in a lawsuit both to you and your agency.


Fire reports

Fire Reports

  • Like a PCR, proper documentation of all dispatched calls is an essential requirement of your job.


Required nifrs information

Location

Date

Times

Apparatus / Personnel responding

Incident type

Property type

Resident / Owner

Level / area of origin

Information about the structure and presence of protection systems

Damage / loss information

Required NIFRS Information


Narrative

Narrative

  • Dispatch information

    • Turnout times greater than 60 sec. will require documentation in NIFRS

      • Causes can include in training/ apparatus checks/pre-plans & inspection/ immediately enroute time inaccurate, ect.

    • Delays will require documentation in NIFRS

      • Traffic / wrong address / train / security gates, ect.

      • Any time greater than a 30 sec. delay will be documented.


Narrative1

Narrative

  • Arrival / Size-up information

  • Command

  • Assignments

    • Mode, Attack, Water supply, Utilities, Search, RIT, Ventilation, Rehab, ect.


Narrative2

Narrative

  • Thermal Imager use

  • Special or unusual actions including deviating from SOP’s

  • Injuries or death (in addition, complete the appropriate NFIRS)

  • Investigation results (note when the Fire Marshal or PD is investigating further)

  • Any damaged or broken equipment (may be an addendum)


Narrative false alarms

Narrative – False Alarms

  • Dispatch information

  • Arrival information

  • Disposition (what you found)

  • Facility member or homeowner you made contact with to confirm the false alarm.


Narrative cancelled enroute

Narrative – Cancelled Enroute

  • Dispatch Information

  • Reason for cancellation

  • Name of the person who cancelled the Fire Department


Practical assignments

Practical Assignments

  • Using the SOAPP method complete a written PCR narrative for the EMS information given.

  • Complete a narrative for the information given for a fire report.


References

References

  • Volusia County Medical Protocols

  • Bledsoe, Cherry, Porter (2003), Essentials of Paramedic Care, Brady; Upper saddle River, NJ

  • IFSTA (2001), Fire Department Company Officer; Third Edition, Stillwater, OK.


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