Chapter 6: EMS Documentation

Importance of EMS Documentation

• Integral part of patient care process.
• Patient Care Report (PCR): Legal document, part of medical and emergency department records.
• Assists in guiding future patient care and quality assurance.

Key Components of a PCR

• Objective Information: Measurable signs like pulse, respiratory rate, blood pressure.
• Subjective Information: Descriptions from patients, like pain levels, nausea.
• Must contain both objective and subjective information, and details of patient care.
• Required to be complete, accurate, and legible.

Legal Implications

• PCRs can be used in legal proceedings.
• Must be professional, factual, accurate, and truthful.
• Errors or omissions could lead to legal issues or job consequences.

Technology in Reporting

• Most EMS providers use electronic tablets for reports.
• Facilitates quality, continuity of care, and billing.

Quality Assurance

• PCRs can be used for medical audits and educational activities.
• Accurate documentation of skills and interventions, successful or not.

Billing and Insurance

• Accurate PCRs essential for insurance billing and avoiding discrepancies.

Incident Review

• PCRs can be used for peer reviews and quality monitoring.

Data Collection and Research

• EMS data helps in research and improving EMS systems.
• National EMS Information System (NEMSIS) collects standardized data.

Additional Documentation Requirements

• Special situations: refusals of care, multiple casualty incidents, etc.
• Ensure thorough documentation in all scenarios.

Record Keeping and Reporting

• Maintain accuracy and timeliness in all reports.
• Avoid jargon, slang, or personal opinions in reports.
• Legal requirements for records maintenance.

Special Situations

• Include documentation for refusal of care, workplace injuries, etc.
• Must understand state laws related to consent and care refusals.

Transfer of Care

• Document recipient care to avoid abandonment allegations.
• Ensure recipient of care signs off.

Electronic Documentation

• Most EMS uses electronic systems; benefits include ease of sharing and data storage.
• Systems should be NEMSIS compliant.

Conclusion

• Accurate, professional documentation is crucial in EMS for legal protection, quality care, and effective billing.
• Always ensure documentation is up to date, accurate, and complete.