Documentation

• #Rowe
• Documentation is an integral part of EMS care. It becomes a part of the patient's medical record and is added to their ED chart
• It is important to document accurately and with the thought of who might read it. A sloppy PCR implies sloppy care
• Reports may include subjective statements made by the patient, but must be free of subjective statements from the provider
• Always document the reason for ambulance transport. If the patient is bed bound, if the patient is ambulatory, if the patient has no other way to get to the hospital—document it!
  • This is good for people who need an ambulance! It makes sure that insurance is billed instead of them
• Don't only document what was done, document who did it! If another provider attempted an IV or took a BGL, document that they did it, not you
  • This is good for liability. If a call pulls you into court, and it says you did everything on that call, then legally you did
• Document all of the objective findings on the scene—how and where the patient was found, any pertinent smells, vehicle damage, etc.
  • You are painting a picture of the scene for everyone who will take care of the patient in the future
• Document any care provided to the patient prior to EMS arrival and who provided it and why. Did the 911 dispatcher direct it? Was there a physician on scene?
  • Don't be responsible for something you didn't do!
• The patient care report is a direct reflection of you as a paramedic—not only the care you provided but also the way you document it. Good medics write good PCRs, bad medics write bad PCRs