This document provides guidelines for EMS documentation, including reasons for documentation such as continuity of care, legal protection, and quality improvement. It discusses SOAP note documentation structure and recommends including a thorough physical exam, assessment, treatment, and patient response. Key components of documentation are outlined for common calls like chest pain, trauma, and abdominal pain. Documentation of patient refusal and things to avoid in reports are also covered.

1. Documentation Brown EMS October 18, 2007

3. If you didn’t write it down it didn’t happen

5. Styles