1. Report Writing
EMS and Fire Reports

2. Why do we write reports? Medical documentation
Administrative information
Research
Legal
Attorneys will have access to YOUR report in a legal preceding

3. 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.

4. SOAPP FORMAT Subjective Chief Complaint
History of present illness (including history of events surrounding the call)
Past medical history

5. SOAPP FORMAT Objective Vital signs (normal/abnormal)
General impression/ physical findings (normal/abnormal in relation to the chief complaint)

6. SOAPP FORMAT Assessment
Working diagnosis and it can be the same as the chief complaint.

7. SOAPP FORMAT Plan Protocol(s) followed Physicians orders
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.

8. SOAPP FORMAT Prehospital Course
Assessment / management performed and how did the patient respond.
This may be short if patient care is transferred quickly

9. 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.

10. 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 .

11. 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

12. 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.

13. 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.)

14. PCR – Cancelled Prior to Arrival
Dispatch information
Reason for cancellation
Time of cancellation, who cancelled your agency.

15. 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.

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

17. 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

18. 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.

19. Narrative Arrival / Size-up information Command Assignments
Mode, Attack, Water supply, Utilities, Search, RIT, Ventilation, Rehab, ect.

20. 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)

21. Narrative – False Alarms
Dispatch information
Arrival information
Disposition (what you found)
Facility member or homeowner you made contact with to confirm the false alarm.

22. Narrative – Cancelled Enroute
Dispatch Information
Reason for cancellation
Name of the person who cancelled the Fire Department

23. 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.

24. 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.