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Communications | Part Four

Documentation

Documentation: the process of recording patient information Proper documentation includes:

  • Record of the scene
  • Patient’s CC
  • Patient’s condition
  • Nature and extent of emergency care given
  • Changes in the patient’s condition
  • Patient’s name, address, age and sex
  • Administrative information ie disposition of the call

Reasons for Documentation

  • #1 Continuation of care, supplying vital info to the ER staff
  • Point out improvements with treatment or deterioration
  • Treatments administered
  • Description of the scene ie. Damage to an accident victim’s car
  • Legal record of the case
  • Record of procedures performed under auspices of licensed physician
  • Demonstrates protocols are being adhered to
  • In compliance with law and meeting the standard of care
  • Tally up different procedures, provides statistics

Run reports

  • Guide system improvements
  • Training programs
  • Revenue collection
  • Research
  • Billing and administrative data
  • Operational statistics
  • Training tools
  • Permanent Record – most lawsuits against EMT-Is relate to improper care
  • May be used in a criminal trial where EMTs testimony can reveal guilt or innocence

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