TB 98 - Emergency Medical Services Report Writing Flashcards
A complete, accurate, and legible EMS Report helps other health care providers plan, coordinate, and document the quality and continuity of each patient’s care.
A well-documented EMS Report reflects:
•All patient assessment findings and observations
•The care provided to the patient
•The patient’s response to medication and other treatment interventions
In addition to being used as an EMS Report, the EPCR furnishes the Department with data used for:
-patient billing
-EMS quality improvement
-identification of training needs
-aiding in the projection of the future allocation of resources
All members must remember to “_____ and ______” before beginning to complete the EPCR.
“assess and intervene”
(Care for the patient always takes priority over documentation of incident information.)
When documenting on the EPCR: enter factual, OBJECTIVE observations and findings only.
Avoid recording personal OPINIONS, SPECULATIVE remarks, or PRESUMPTIONS.
Since ALL MEMBERS whose signatures appear on the document are assumed to concur with its contents, it is imperative that the form be ________
read prior to signing.
As our written reports often reflect directly UPON US, clear, concise, and ______ reports are a necessity.
complete
Although most members use the teletype printout to record their incident notes, many have found preprinted scratch pads to be helpful.
The two LEAST professional, and therefore least advisable method, is writing on?
Writing on hand or gurney sheets
Complete the EPCR as soon as possible AFTER the resolution of each incident.
If transporting, when is it best to complete the EPCR?
At the receiving facility.
(This affords optimal patient care, both on scene and during transport)
To maximize the clarity of documentation, a CHRONOLOGICALLY ORDERED written commentary is advisable.
This orderly arrangement should encompass:
•Any delayed response information
•Initial observations of the scene
•Baseline patient assessment findings
•Treatment interventions rendered
•The patient’s response to such care
•Information regarding the patient’s final disposition/incident resolution
It is inherently more reliable and credible to use the patient’s and/or bystander’s OWN WORDS in documentation.
Utmost accuracy can be attained by recording the patient’s responses to _____ and ______ assessment questions.
PQRST and SAMPLE
How should a patient’s/bystander’s own words be documented during an assessment?
Their direct quotes should be identified with Quotation Marks.
Do not erase, write over, scribble out, or white out entries, as this may imply an intent to falsify documents.
Errors or mistakes must be legible even after they have been corrected. Therefore, the “_______” method of correction should be utilized.
line-through method.
(Use a single line to indicate an unwanted entry. Place your initials ABOVE the lined-through entry)
Should you need to enter information that is late, write it in, and note “LATE ENTRY.”
What else should be included to signify the late entry?
Include the date and time the late entry was made and initial it.
The greatest potential for criticism arising from EMS incidents occurs in what situations?
in those situations in which no “hands on” patient contact was made (i.e., no patient assessment was performed and/or no vital signs were taken).
The basic premise of most law suits involving charges of negligence, improper treatment, or omissions of care stems from the allegation that members FAILED to perform to an appropriate STANDARD OF CARE.
The legal standard for evaluating the quality of care is generally based on?
A member’s ACTIONS (or inactions) in comparison to the generally accepted standard of care.
As our EMS system evolves toward standing orders, members will be better equipped to render appropriate patient care if they frequently review the “Three Ps”:
policies, procedures, and protocols.
