Documentation (updated 4 2011)

“ If you didn’t write it… … You didn’t do it! Documentation

Documentation is very important: ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Importance: ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Elements of a Properly written EMS Document ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Accurate ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Legible: (Handwritten ACRs) ,[object Object],[object Object],[object Object]

Kellyology! ,[object Object],[object Object],[object Object]

Spell Checked and Grammatically Correct. ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Kellyology! (Grammar & Spelling) ,[object Object],[object Object],[object Object],[object Object],[object Object]

Kellyology! Electronic PCRs ,[object Object],[object Object]

Timely ,[object Object],[object Object],[object Object],[object Object],[object Object]

Unaltered ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Free of non-professional/extraneous information ,[object Object],[object Object],[object Object],[object Object],[object Object]

Document Revision / Correction

How To Revise a Document ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Who revises the document? ,[object Object]

Acceptable methods ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Acceptable methods ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Head to Toe approach ,[object Object]

Body systems approach ,[object Object],[object Object],[object Object],[object Object],[object Object]

Call Incident Approach ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

S.O.A.P ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

C.H.A.R.T.E. ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Special Considerations of Documentation

Documentation of Refusals ,[object Object],[object Object],[object Object],[object Object]

Document decisions/events where care and transportation were not needed ,[object Object],[object Object],[object Object],[object Object],[object Object]

Documentation in Mass casualty situations ,[object Object],[object Object],[object Object],[object Object],[object Object],www.jimdiffin.wordpress.com

Consequences of Inappropriate Documentation

Implications to medical care ,[object Object]

Legal Implications ,[object Object],[object Object]

REMINDER: ,[object Object],[object Object],[object Object]

In Closing….. ,[object Object],[object Object]

Documentation (updated 4 2011)

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