This document discusses the principles and purposes of EMS documentation. It emphasizes that the prehospital care report (PCR) is the sole written record of an ambulance call and should include both narrative and check-box sections. The PCR is used for medical, administrative, research, and legal purposes. Special situations like patient refusals, non-transport calls, and mass casualty incidents require specific documentation approaches. Proper documentation is important for patient care, legal protection, and system improvement.

1. Documentation

2. Topics
 Principles and Purposes of
EMS Documentation
 Medical Terminology & Abbreviations
 Roles of Documentation
 Subjective & Objective
Documentation
 Evaluation of a Finished Document
 Special Situations

3. Introduction
 Your written prehospital care
report (PCR) is the only true
factual record of events.
 Your PCR is your sole
permanent, complete written
record of events during the
ambulance call.

4. Uses for PCR’s
 Medical
 Administrative
 Research
 Legal

5. Run data in a PCR helps agencies to
improve patient care.

6. Complete both the narrative and
check-box sections of every PCR.

7. General Considerations
 Use appropriate medical
terminology.
 Use acceptable and approved
abbreviations and acronyms.
If you do not know how to spell
a word, look it up or use
another word…

8. Some systems use check boxes, some
use bubble-sheets, and others use
electronic documentation

9. Times
 Whenever possible, record all
times from the same clock.
 When that is not possible, be
sure that all the clocks and
watches you use are
synchronized.

10. Communications
 The communications with the
hospital are another important
item to document.
 Document ANY medical advice or
orders you receive and the results
of implementing that advice and
those orders.

11. Pertinent Negatives
 Document all findings of your
assessment, even those that
are normal.

12. Oral Statements
 Whenever possible, quote the
patient—or other source of
information—directly.
Example: Bystanders state the
patient was “acting bizarre and
threatening to jump in front of
the next passing car.”

13. Elements of Good Documentation
 Accuracy
 Legibility
 Timeliness
 Absence of alterations
 Professionalism

14. The Proper Way to Correct a
Prehospital Care Report

15. Professionalism
 Never include slang, biased
statements, or irrelevant
opinions.
 Include only objective
information.
 Always write and speak clearly.

16. 2 Narrative Formats
CHART SOAP
 Chief complaint  Subjective
 History  Objective
 Assessment  Assessment
 Rx (treatment)  Plan
 Transport

17. Narrative Writing
 Subjective part of your narrative
comprises any information that you
elicit during your patient’s history.
 Objective part of your narrative
usually includes your general
impression and any data that you
derive through inspection,
palpation, auscultation, percussion,
and
diagnostic testing.

18. Special Considerations
 Patient refusals
 Services not needed
 Mass casualty incidents

19. Patient Refusals
 Patients retain the right to refuse
treatment or transportation if they
are competent to make that
decision.
 Two main types of refusals:
 Person who is not seriously
injured and does not want to go to
the hospital
 The patient refuses even though
you feel he needs it.

20. A patient’s refusal of care requires
careful documentation.

21. One Example of a
“Refusal of Care” Form

22. Services Not Needed
 Some systems allow paramedics to
determine patients that do not
require ambulance transportation.
 While this may help to reduce
ambulance utilization, the risks of
denying transport are even greater
than those of a refusal.
 Evaluate all patients with even
minor injuries and document
appropriately.

23. Mass Casualty Incidents
 Multiple patients, mass casualties,
and disasters all present special
documentation problems.
 Weigh your patient’s needs against
the demand for complete
documentation.
 Follow local guidelines and utilize
the appropriate forms such as
triage tags.

24. Triage tags are used to record vital
information on each patient quickly.

25. Consequences of
Inappropriate Documentation
 Inappropriate documentation can
have both medical and legal
consequences.
 Do not guess about your patient’s
problems.
 Write neatly, clearly, and legibly.
 Complete your form completely.
 Spelling counts!

26. Summary
 Principles and Purposes of
EMS Documentation
 Medical Terminology & Abbreviations
 Roles of Documentation
 Subjective & Objective
Documentation
 Evaluation of a Finished Document
 Special Situations