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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

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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