This document discusses the importance of proper documentation for EMTs. It emphasizes that medical records should be accurate, complete, legible, and free of extraneous information. Good documentation is essential for continuity of patient care, regulatory compliance, quality assurance, research, and legal protection. EMTs are instructed to record only objective facts and observations, correct any errors, and document treatment provided and patient refusal of treatment.

1. Temple College EMS Professions 1
RECORDS & REPORTS
EMERGENCY MEDICAL TECHNICIAN
- BASIC

2. Temple College EMS Professions 2
PURPOSE OF
DOCUMENTATION
• Continuity of patient care
• Regulatory requirements
• Quality assurance
• Research
• Justification of treatment
• Protection for personnel
• Administration

3. Temple College EMS Professions 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. Temple College EMS Professions 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. Temple College EMS Professions 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. Temple College EMS Professions 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. Temple College EMS Professions 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. Temple College EMS Professions 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. Temple College EMS Professions 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. Temple College EMS Professions 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. Temple College EMS Professions 11
DOCUMENTATION
• If you have a prolonged scene time, say
why
• If times are to be documented on your
report, do so accurately!

12. Temple College EMS Professions 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. Temple College EMS Professions 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. Temple College EMS Professions 14
PATIENT REFUSAL
• If the Pt. will not sign, have the document
signed by family, law enforcement, or
bystander