DocumentationDocumentationDocumentationDocumentation

EMT 170 EMT 170 Emergency Communications and Emergency Communications and

Patient TransportationPatient Transportation(Cars & Radios)(Cars & Radios)

Documentation – Purpose

• Provides a record of scene information that may not be available from any other source

• Provides information for the continuity of patient care from one healthcare provider to another

• Provides a record of specific pre-hospital interventions performed or attempted

• Provides medical legal evidence• Reveals any significant changes in the

patient’s condition• Provides an internal tool for statistics,

budgeting, QA and education

Patient Care Report – Types of Reports

• Traditional written report– Typically provides check boxes and a

narrative section– EMT completes it in written form

• Computer-based report– Generated on an electronic clipboard or

mobile data terminal– EMT enters information by special

instrument or keyboard

Written Patient Care Report(PCR)

Written Patient Care Report(PCR)

Computer Based Report System

PCR-Report Elements• Run data

• Patient data

• Narrative information

Run Data• Service name • Unit number• Crew license numbers and/or

names• Location of call• Response times mileage

Patient Data• Patient’s name

• Age

• Location of

patient

• Pupillary

response

• Assessment

• Address

• Sex

• LOC

• Vital signs

• Care provided

• DOB

• MOI/NOI

• Sensation

• PMH

• Response to

treatment

Narrative• Used to document

– Patient complaint/history– Observation– Physical assessment finding– Care delivered by EMS crew– Changes in patient condition

•SOAPSOAP

General Guidelines

• Collect all patient information• Complete all blanks and check all

pertinent boxes on call report form• Do not leave any spaces blank,

mark “N/A” if item does not apply• Begin narrative by documenting

the patient's LOC

General Guidelines (cont.)

• Attach EKG documentation (where applicable) with date, time and patient's name on it

• Sign the report• Leave a copy of the report with

the patient’s chart

Items to Document

• Patient’s chief complaint using patient’s own words within quotation marks if possible

• History of present illness or injury using OPQRST format

• Physical assessment findings including pertinent positives and pertinent negatives

• Significant pertinent past medical history including surgeries, hospitalizations, illnesses or injuries

Items to Document (cont.)

• Allergies and current medications• Interventions, who performed

them, time performed, and the patient’s response or lack of response to interventions

• Vital signs and times obtained

Writing a Narrative

• Use plain language and medical terminology

• Avoid slang

• Use only recognized abbreviations

• Spelling general neatness are imperative to convey professionalism

SOAP MethodS – subjective

– Information the patient tells you– Patient symptoms

O – objective– Information the EMT observes about the scene and

possible injuries

A – assessment– EMTs evaluation of the situation, the patient’s chief

complaint and findings based on the exam

P – plan– The plan of action and care delivered the EMT

Other Narrative Forms

• Head-to-toe format

• Chronological format

Correcting Mistakes

• Do not erase or mark out a mistake– Draw a single line through the error

and place initials beside the line– Add the correct information following

the correction– If information was initially omitted,

add a note with additional information, the date, and the EMTs initials

Errors

• DO NOT attempt to cover mistake

• Document what did or did not happen and what corrective action (if any) was taken

• Falsifying information on a PCR is harmful to the patient and may lead to the suspension or revocation of the EMTs certification and other legal action

Summary• Documentation is the most important non-

clinical skill possessed by the EMT• The patient care report must be accurate and

report both subjective and objective findings, physical assessment results, care and treatment rendered and any significant observation of the scene

• The PCR is considered a legal document that serves as an official record of care given

• The PCR is the EMTs first line of defense if questions are later raised about the incident