Documentation Flashcards
Purpose of a PCR
provides important information to those that will continue patient care after your work is done
Documentation rule No. 1
if you did it, write it down. if you did not do it, do not write it down
Documentation rule No. 2
it is much better to document well than to explain later why you didnt
Minimum data on the PCR
Times
Patient info
Admin info
Narrative
What times are important to list?
dispatch time time in route to call time on scene patient contact time time en route to hospital arrival time at hospital time transfer of care
Documentation rule No. 3
if times are proven inaccurate, you may be sent to court
Important patient information
age sex chief complaint level of consciousness minimum of two sets of vital signs assessments completed on patient all treatments provided response to treatment
Important admin information
address of call
date of call
your unit
name and certification level of all EMS providers on call
F.A.C.T. Documentation
Factual
Accurate
Complete
Timely
Documentation rule No. 4
Document objectively, no subjectively
Objective Documentation
based on facts, findings, or observations that are highly difficult to dispute
Subjective Documentation
based on opinions or perceptions and can easily be disputed
Associated Symptoms
patient complaints in addition to the chief complaint
Pertinent Negatives
signs or symptoms you have reason to suspect, but patient denies having
Documentation Rule No. 5
Spelling counts
