Clinical Documentation SOP Flashcards
1
Q
Summarise the clinical documentation SOP
A
- Aware that they are essential for continuity of care and an official record
- Aware that will be read by other agencies
Guidance:
- GMC standards for notes
On scene:
- Paper summary on scene, photo onto HEMSbase
- Do diagnosis of death form on ePRR
Returning to base:
- HEMSbase should have full entry plus photos, code summaries, ECGs
- Can do minimum documentation then complete rest within 24hrs
- Subject to review by leadership team
