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Communication | Part Five | Report Writing

Rules for Documenting

If it wasn’t documented, you didn’t do it, and if you didn’t do it, don’t document it.

  • Be accurate and complete, precise and comprehensive
  • Be objective, don’t assume anything
  • Be specific, don’t generalize
  • Write legibly, clearly and concisely. Make sure carbon copies are legible too
  • Use a ballpoint pen so information can’t be tampered with
  • Use correct spelling, carry a dictionary if you need one
  • Use abbreviations and acronyms with care, and only those approved by your EMS system
  • Keep your run report clean
  • Promptly record information – the longer you wait, the more you will miss. Do not delay or compromise patient care
  • Be consistent
  • Be professional – the report will be scrutinized by all sorts of people. Don’t use jargon, slang, libel/slander, irrelevant opinions
  • Check for accuracy and completeness
  • Practice the skills

Systems of Narrative Writing

  • Majority is patient information
  • Demographics, history, and physical examination data
  • All systems should start with patient’s age, sex, CC and how patient was initially found
  • SOAP Format writing
    • Subjective
    • Objective
    • Assessment
    • Plan
  • Head to Toe Method
  • Body Systems: better suited to nursing
  • Chronological method – everything written with a time in front, what was done and when

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