1 RECORDS & REPORTS EMERGENCY MEDICAL TECHNICIAN - BASIC

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

3 A GOOD MEDICAL RECORD IS.. Accurate –Document facts and observations ONLY –Double-check numerical entries –Recheck spellings –If you make an error, DOCUMENT IT

4 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?

5 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

6 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”

7 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

8 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

9 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

10 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!

11 DOCUMENTATION If you have a prolonged scene time, say why If times are to be documented on your report, do so accurately!

12 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

13 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

14 PATIENT REFUSAL If the Pt. will not sign, have the document signed by family, law enforcement, or bystander