Lesson 3.8: Documentation

Objectives

By the end of this lesson, the EMT-Basic should be able to:

1. Explain the components of the written report and list the information that should be included in the written report.
2. Identify the various sections of the written report.
3. Describe what information is required in each section of the prehospital care report and how it should be entered.
4. Define the special considerations concerning patient refusal.
5. Describe the legal implications associated with the written report.
6. Discuss all state and/or local record-keeping and reporting requirements.
7. Explain the rationale for patient care documentation.
8. Explain the rationale for the EMS system gathering data.
9. Explain the rationale for using medical terminology correctly.
10. Explain the rationale for using an accurate and synchronous clock so that information can be used in trending.
11. Complete a prehospital care report.