Report Writing EMS and Fire Reports.

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Presentation transcript:

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

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

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

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.

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

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 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 - 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 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 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 Dispatch information Reason for cancellation Time of cancellation, who cancelled your agency.

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 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

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.

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

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

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

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 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.