Bledsoe v1 ch10_lecture

Copyright © 2017, 2013, 2009 Pearson
Education, Inc. All Rights Reserved.
Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
Paramedic Care: Principles & Practice
Volume 1, 5e
Chapter 10
Documentation

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
Multimedia Directory
Slide 29 Explaining Medical Terminology Video

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
Standard
• Preparatory (Documentation)

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
Competency
• Integrates comprehensive knowledge of EMS
systems, the safety and well-being of the
paramedic, and medical–legal and ethical issues,
which is intended to improve the health of EMS
personnel, patients, and the community.

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
Introduction
• Prehospital care report (PCR): factual record of
events that occur during EMS call or other patient
contact.
– Describes assessment and care throughout emergency
call
– Documents exactly what you did, when you did it,
effects of interventions
– Sole permanent, complete written record

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
Introduction
• PCR Three Major Goals
– To provide information to subsequent health care
professionals about patient and treatments provided in
prehospital setting
– To provide essential information for proper billing of
patient
– To provide legal record of the call's circumstances

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
Uses for Documentation
• Medical
– PCR can tell emergency department staff of patient's
condition before arrival at hospital.
– Baseline for comparing assessment findings and
detecting trends that indicate improvement or
deterioration.

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
• Medical
– Surgical staff: MOI and other findings during primary
assessment.
– Floor or intensive care unit staff: information about
original condition.
– Information from people at scene; circumstances that
led to event or MOI

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
Figure 10-1 The run data in a prehospital care report is vital to your agency's efforts to improve
patient care.
(© Kevin Link/Science Source)

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
• Administrative
– Gather information for quality improvement and system
management.
 Response times
 Call location
 Use of lights and siren
 Date and time

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
• Research
– Analyze recorded data to determine efficacy of
medical devices or interventions.
– Use data to cut costs, alter staffing, shorten response
times.
– Some systems use computerized or electronic PCRs
and computerized database to analyze data.

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
Figure 10-2 The handheld electronic clipboard enables you to enter your prehospital care report
directly into a computer.

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
• Legal
– PCR permanent part of patient's medical record.
– Lawyers may refer to it when preparing court actions.
– In legal proceeding, it might be sole source of
information about the case.
– May serve as evidence in criminal case

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
• Legal
– Always write PCR as if you will have to refer to it
someday in court proceeding.
– Describe patient's condition when you arrived and
during care, status on arrival at hospital.
– Document condition before and after any interventions.
– Avoid writing subjective opinions.

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
General Considerations
• Every EMS system has its own specific
requirements for documentation.
– Reports with check boxes
– Bubble sheets
– Computerized documentation

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
• Medical Terminology
– Use appropriate medical terminology.
• Abbreviations and Acronyms
– Use correct abbreviations and acronyms.
– Formed from initial letters of words they stand for

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
Table 10-1 Standard Charting Abbreviations (1 of 12)
Patient Information/Categories
Asian A Medications Med
Black B Newborn NB
Chief complaint CC Occupational history OH
Complains of c/o Past history PH
Current health status CHS Patient Pt
Date of birth DOB Physical exam PE
Differential diagnosis DD Private medical doctor PMD
Estimated date of confinement EDC Review of systems ROS
Family history FH Signs and symptoms S/S
Female ♀ Social history SH
Hispanic H Visual acuity VA
History Hx Vital signs VS
History and physical H&P Weight Wt
History of present illness HPI White W
Impression IMP Year-old y/o
Male ♂

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
Table 10-1 (continued) Standard Charting Abbreviations (2 of 12)
Body Systems
Abdomen Abd Gynecological GYN
Cardiovascular CV Head, eyes, ears, nose, and throat HEENT
Central nervous system CNS Musculoskeletal M/S
Ear, nose, and throat ENT Obstetric OB
Gastrointestinal GI Peripheral nervous system PNS
Genitourinary GU Respiratory Resp
Common Complaints
Abdominal pain abd pn Lower back pain LBP
Chest pain CP Nausea/vomiting n/v
Dyspnea on exertion DOE No apparent distress NAD
Fever of unknown origin FUO Pain Pn
Gunshot wound GSW Shortness of breath SOB
Headache H/A Substernal chest pain Sscp

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
Diagnoses
Abdominal aortic aneurysm AAA Chronic obstructive pulmonary
disease
COPD
Abortion Ab Chronic renal failure CRF
Acute myocardial infarction AMI Congestive heart failure CHF
Adult respiratory distress syndrome ARDS Coronary artery bypass graft CABG
Alcohol ETOH Coronary artery disease CAD
Atherosclerotic heart disease ASHD Cystic fibrosis CF
Dead on arrival DOA Multiple sclerosis MS
Deep vein thrombosis DVT Non-insulin-dependent diabetes
mellitus
NIDDM
Delirium tremens DTs Organic brain syndrome OBS
Diabetes mellitus DM Otitis media OM
Dilation and curettage D&C Overdose OD
Duodenal ulcer DU Paroxysmal nocturnal dyspnea PND
End-stage renal failure ESRF Pelvic inflammatory disease PID
Epstein-Barr virus EBV Peptic ulcer disease PUD

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
Diagnoses
Foreign body obstruction FBO Pregnancies/births (gravida/para) G/P
Hepatitis B virus HBV Pregnancy-induced hypertension PIH
Hiatal hernia HH Pulmonary embolism PE
Hypertension HTN Rheumatic heart disease RHD
Infectious disease ID Sexually transmitted disease STD
Inferior wall myocardial infarction IWMI Transient ischemic attack TIA
Insulin-dependent diabetes mellitus IDDM Tuberculosis TB
Intracranial pressure ICP Upper respiratory infection URI
Mass casualty incident MCI Urinary tract infection UTI
Mitral valve prolapse MVP Venereal disease VD
Motor vehicle crash MVC Wolff-Parkinson-White syndrome
(disease)
WPW
Medications
Angiotensin-converting enzyme ACE Lactated Ringer's, Ringer's lactate LR, RL
Aspirin ASA Magnesium sulfate MgSO4
Bicarbonate HCO−
3 Morphine sulfate MS

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
Medications
Birth control pills BCP Nitroglycerin NTG
Calcium Ca2+ Nonsteroidal anti-inflammatory
agent
NSAID
Calcium channel blocker CCB Normal saline NS
Calcium chloride CaCl2 Penicillin PCN
Chloride Cl− Phenobarbital PB
Digoxin Dig Potassium K+
Dilantin (phenytoin sodium) DPH Sodium bicarbonate NaHCO3
Diphendydramine DPHM Sodium chloride NaCl
Diphtheria-pertussis-tetanus DPT Tylenol APAP
Hydrochlorothiazide HCTZ
Anatomy/Landmarks
Abdomen Abd Anterior-posterior A/P
Antecubital AC Distal interphalangeal (joint) DIP
Anterior axillary line AAL Dorsalis pedis (pulse) DP
Anterior cruciate ligament ACL Gallbladder GB

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
Anatomy/Landmarks
Intercostal space ICS Midaxillary line MAL
Lateral collateral ligament LCL Posterior axillary line PAL
Left lower lobe LLL Posterior cruciate ligament PCL
Left lower quadrant LLQ Proximal interphalangeal (joint) PIP
Left upper lobe LUL Right lower lobe RLL
Left upper quadrant LUQ Right lower quadrant RLQ
Left ventricle LV Right middle lobe RML
Liver, spleen, and kidneys LSK Right upper lobe RUL
Lymph node LN Right upper quadrant RUQ
Medial collateral ligament MCL Temporomandibular joint TMJ
Metacarpophalangeal (joint) MCP Tympanic membrane TM
Metatarsophalangeal (joint) MTP
Physical Exam/Findings
Arterial blood gas ABG Heel-to-shin (cerebellar test) H → S
Bilateral breath sounds BBS Hemoglobin Hgb
Blood sugar BS Inspiratory Insp

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
Breath sounds BS Jugular venous distention JVD
Cardiac injury profile CIP Laceration Lac
Central venous pressure CVP Level of consciousness LOC
Cerebrospinal fluid CSF Moves all extremities (well) MAEW
Chest X-ray CXR Nontender NT
Complete blood count CBC Normal range of motion NROM
Computerized tomography CT Palpation Palp
Conscious, alert, and oriented CAO Passive range of motion PROM
Costovertebral angle CVA Point of maximal impulse PMI
Deep tendon reflexes DTR Posterior tibial (pulse) PT
Dorsalis pedis (pulse) DP Pulse P
Electrocardiogram EKG,
ECG
Pupils equal and reactive to light PEARL
Electroencephalogram EEG
Pupils equal, round, reactive to
light and accommodation
PERRLA
Expiratory Exp Range of motion ROM

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
Extraocular movements (intact) EOMI Respirations R
Fetal heart tones FHT Tactile vocal fremitus TVF
Full range of motion FROM Temperature T
Full-term normal delivery FTND Unconscious Unc
Heart rate HR Urinary incontinence UI
Heart sounds HS
Miscellaneous Descriptors
After (post-)
𝑃
− Not applicable n/a
After eating pc Number No or #
Alert and oriented A/O Occasional Occ
Anterior ant. Pack years pk/yrs,
p/y
Approximate ≈ Per /
As needed prn Positive +
Before (ante-) ā Posterior post.

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
Miscellaneous Descriptors
Before eating (ante cibum, before
meal)
Postoperative PO
Body surface area (%) BSA Prior to arrival PTA
Celsius C Radiates to →
Change Δ Right R
Decreased ↓ Rule out R/O
Equal = Secondary to 2°
Fahrenheit F Superior sup.
Immediately stat Times (for 3 hours) × (×3h)
Increased ↑ Unequal ≠
Inferior inf. Warm and dry W/D
Left L While awake WA
Less than < With (cum)
Moderate mod. Within normal limits WNL
More than > Without (sine)
Negative – Zero 0
No, not, none Ø

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
Treatments/Dispositions
Advanced cardiac life support Intermittent positive-pressure
ventilation
IPPV
Advanced life support ALS Long spine board LSB
Against medical advice AMA Nasal cannula NC
Automated external defibrillator AED Nasogastric NG
Bag-valve mask BVM Nasopharyngeal airway NPA
Basic life support BLS No transport—refusal NTR
Cardiopulmonary resuscitation CPR Nonrebreather mask NRM
Carotid sinus massage CSM Nothing by mouth NPO
Continuous positive airway pressure CPAP Occupational therapy OT
Do not resuscitate DNR Oropharyngeal airway OPA
Endotracheal tube ETT Oxygen O2
Estimated time of arrival ETA Per square inch
External cardiac pacing ECP Physical therapy PT
Positive end-expiratory pressure PEEP Treatment Tx
Short spine board SSB Turned over to TOT
Therapy Rx Verbal order VO

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
Medication Administration/Metrics
Centimeter cm Keep vein open KVO
Cubic centimeter cc Kilogram kg
Deciliter dL Liter L
Drop(s) gtt(s) Liters per minute Lpm, L/min,
liters/min
Drops per minute gtts/min Microgram mcg
Every Q Milliequivalent mEq
Grain gr Milligram mg
Gram g, gm Milliliter mL
Hour h, hr, or ° Millimeter mm
Hydrogen-ion concentration pH Millimeters of mercury mmHg
Intracardiac IC Minute min
Intramuscular IM Orally PO
Intraosseous IO Subcutaneous SC, SQ
Intravenous IV Sublingual SL
Intravenous push IVP To keep open TKO
Joules J

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
Cardiology
Atrial fibrillation AF Paroxysmal atrial tachycardia PAT
Atrial tachycardia AT Paroxysmal supraventricular
tachycardia
PSVT
Atrioventricular AV Premature atrial contraction PAC
Bundle branch block BBB Premature junctional
contraction
PJC
Complete heart block CHB Premature ventricular
contraction
PVC
Electromechanical dissociation EMD Pulseless electrical activity PEA
Idioventricular rhythm IVR Supraventricular tachycardia SVT
Junctional rhythm JR Ventricular fibrillation VF
Modified chest lead MCL Ventricular tachycardia VT
Normal sinus rhythm NSR Wandering atrial pacemaker WAP

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
Explaining Medical Terminology Video
Click here to view a video on the topic of medical terminology.
Back to Directory

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
• Times
– Times you record on PCR considered official times of
incident.
– For medical and legal purposes, ensure their accuracy.

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
• Times
– Time call received
– Dispatch time
– Time of arrival at scene
– Time of departure from scene
– Time of arrival at hospital
– Time back in service
– Record all times from same clock.

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
• Communications
– PCR likely only permanent record of your discussion
with medical direction physician.
– Document medical advice or orders you receive and
results of implementing.
– Document what you reported to physician and/or
discussed.
– Document physician's name.

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
• Pertinent Negatives
– Document all findings of assessment, even those that
are normal.
– Negative findings; vary for each chief complaint

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
• Oral Statements
– Statements of witnesses, bystanders, patient
– Document MOI, patient's behavior, events leading up to
emergency, first aid or medical care others rendered
before you arrived
– At crime scenes, document safety-related information.

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
• Additional Resources
– Document all resources involved in event:
 Air-medical service
 EMS, fire, rescue/extrication
 Law enforcement agencies
 Physicians/medical direction physicians
– Document integration carefully.

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
Elements of Good Documentation
• Completeness and Accuracy
– Accurate PCR: precise but comprehensive.
– Include all relevant information; exclude superfluous
information.
– Complete both narrative and check-box sections.
– Narrative core of the documentation

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
• Completeness and Accuracy
– Make sure information in checked boxes and narrative
is consistent.
– Use proper spelling, approved abbreviations, proper
acronyms.

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
• Legibility
– Poor penmanship and illegible reports lead to poor
documentation.
– Handwriting must be neat.
– Other members of health care team may use report for
medical information, research, or quality improvement.

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
• Timeliness
– Avoid writing report in ambulance during transport of
patient.
– Complete paperwork once patient care is transferred.
– Complete report immediately after emergency call.

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
• Absence of Alterations
– If you make a mistake writing your report, simply cross
through error with one line and initial it.
– Do not scribble over or blacken out any area of call
report.
– Never try to hide an error.
– If you find error after you've written several sentences,
submit addendum.

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
Figure 10-5 The proper way to correct a PCR is to draw a single line through the error, write the
correct information beside it, and initial the change.

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
• Absence of Alterations
– Whenever possible, have everyone involved in call
read or reread PCR.
– Make corrections before you submit report.
– Write any addendum to your report as soon as you
realize that you made error or that additional
information needed.

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
• Professionalism
– Write report in professional manner.
– Write cautiously; avoid remarks that might be
construed as derogatory.
– Avoid jargon, slang, biased statements, irrelevant
opinions.
– Write and speak carefully.

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
Narrative Writing
• Narrative depicts call at length.
• Describes assessment findings in detail
• Narrative Sections
– Subjective narrative
– Objective narrative
– Assessment/management plan

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
Narrative Writing
• Subjective Narrative
– Information elicited during patient's history:
 Chief complaint (CC)
 History of present illness (HPI)
 Past history (PH)
 Current health status (CHS)
 Review of systems (ROS)
 Mechanism of injury (MOI)

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
Narrative Writing
• Objective Narrative
– General impression; data through inspection, palpation,
auscultation, percussion, diagnostic testing:
 Vital signs
 Physical exam
 Tests

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
Narrative Writing
– Head-to-toe approach: well suited for any call when
you perform entire physical exam.
 Encourages you to be systematic and thorough
 Appropriate for major trauma and serious medical
emergencies

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
Narrative Writing
– Body systems approach: focuses on body systems
instead of body areas.
 Suited to screening/preadmission exams
 In emergency medicine, focus only on system(s) involved in
current illness or injury.
 One of the most comprehensive approaches to documentation.

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
Narrative Writing
• Assessment/Management Plan
– Document what you believe to be patient's problem.
– Field diagnosis (impression)
– Rule out identifies diagnoses you believe emergency
physician should evaluate.
– Record complete management plan from start to finish.

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
Narrative Writing
• General Formats
– SOAP Format
 S = Subjective
 O = Objective
 A = Assessment
 P = Plan

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
Narrative Writing
• General Formats
– CHART Format
 C = Chief complaint
 H = History
 A = Assessment
 R = Rx (treatment)
 T = Transport

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
Narrative Writing
• General Formats
– Patient Management
 Preferred for some critical patients
 Focus on managing variety of patient problems; not on
conducting thorough history and physical exam.
 Chronological account
 Assessment and management of conditions

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
Narrative Writing
• General Formats
– Call Incident Approach
 Emphasizes MOI, surrounding circumstances, how incident
occurred.
 Documenting trauma call with significant MOI
 Suitable when events surrounding call might be significant.

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
Special Considerations
• Patient Refusals
– Person not seriously ill or injured; does not want to go
to hospital
 Patient signs PCR "Refusal of Care," and you return to service.
– Patient refuses care even though he needs it; against
medical advice (AMA).
 Patients retain right to refuse treatment or transportation if
competent.

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
– Document that you believe patient was competent to
refuse care.
– Document patient has adequate mental status and
understands field diagnosis, alternative treatments,
consequences of refusing care.
– Record reason for refusing care.

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
Table 10-2 Refusal of Care Documentation Checklist
• Thorough patient assessment
• Competency of patient
• Your recommendation for care and transport
• Explanation to the patient about possible consequences of refusing
care, including possibility of death, if appropriate
• Other suggestions for accessing care
• Willingness to return if patient changes mind
• Patient's understanding of statements and suggestions and apparent
competence to refuse care based on that understanding

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
– Inform of potential complications from injuries that
might not be obvious.
– Document any involvement of patient's family or
friends.
– May need to make clear possibility of patient's dying.

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
– In many systems, you must contact medical direction
physician before allowing patient to refuse transport.
– Note that you instructed him to call ambulance or go to
emergency department if condition worsens.
– Include narrative with quotations and statements from
others on scene.

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
• Services Not Needed
– Document transport was unnecessary.
– Document any discussion you have with emergency
physician.
– If ambulance canceled en route, document canceling
authority and time of notification.
– Document if you arrive on scene and find no patients.

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
• Multiple Casualty Incidents
– Multiple patients, mass casualties, and disasters have
special documentation problems.
– Weigh patients' needs against demand for complete
documentation.
– Document as much as possible, as quickly as possible,
on PCR.

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
– Complete documentation later as addendum.
– Document only what you know to be factual and
accurate.
– Be familiar with local policies and procedures for
documenting these situations.

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
– Triage tag: patient's vital information—name, major
injuries, vital signs, treatment, priority (urgent,
nonurgent).
– Affix it to patient; remains there throughout event
– Transfer its information to PCR later

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
Consequences of
Inappropriate Documentation
• Medical Consequences
– Potentially most serious
– Can affect patient care for hours/days after ambulance
call ends
– Good documentation now enables good care later.

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
Consequences of
Inappropriate Documentation
• Legal Consequences
– Poor, incomplete, inaccurate documentation
encourages anyone who is pursuing frivolous lawsuit.
– Good documentation discourages such actions.
– Remember: if it is not documented, you did not do it.

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
Electronic Patient Care Records
• Benefits of ePCR Systems
– Greater ease of data collection and analysis
– Consistent, uniform, easily read patient chart
– Reduction of poor penmanship and spelling errors
– Opportunity for EMS administrator to configure and
alter the software.

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
– Integration with dispatch software, billing services,
regulatory agencies
– Interface with medical devices
– Better quality assurance processes, chart reviews,
feedback to EMT or paramedic

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
– Data "pick from" list: values presented and EMT selects
item or items from list.
– Graphic interface
– Manual entry

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
• Drawbacks of ePCR Systems
– Prohibitive cost
– Fees for technical support, upgrades, support from
software vendor
– Requires personnel to administer and deal with day-to-
day issues
– Institutional reluctance; push-back from field crews

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
Closing
• As paramedic you will assume responsibility for
your documentation.
• It is one of the most important parts of EMS call.
• Ensuring documentation is complete, accurate,
legible, appropriate is one of your professional
responsibilities.

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
Closing
• Your report's confidentiality cannot be
overemphasized.
• Confidentiality is patient's legal right.
• Electronic charting will become common in the
future; effective documentation still applies.

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
Summary
• All EMS records should possess same basic
attributes.
• Appropriate terminology, proper spelling, accepted
abbreviations and acronyms, accurate times are
essential.

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
Summary
• Description of assessment and interventions
(pertinent negatives and communications with on-
line physicians) important.
• All personnel and resources involved in call must
be documented.
• Record must be accurate and precise, free of
jargon, neatly written.

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
Summary
• Corrections made properly, including use of
addendum when appropriate.
• Systems of documentation: CHART and SOAP
formats; use one consistently.
• Special situations (multiple patients and refusals
of transportation) require extra attention.

Bryan E. Bledsoe
Richard A. Cherry
Robert S. Porter
Summary
• Complete narrative and check boxes best way to
ensure necessary information documented.
• Documentation one of the most important parts of
EMS call.
• Permanent record of ambulance call.

Bledsoe v1 ch10_lecture

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