Report Writing and Documentation

(2 hours: Basic, Intermediate and Paramedic levels)

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1. Medical Legal Considerations (30 minutes)
   1. Protection
      1. Patient
      2. Provider
      3. Profession
   2. Patient protection
      1. Document what is found at the scene
      2. Document patient condition
      3. Provide subsequent providers with information to continue care
   3. Provider protection
      1. Court cases
      2. Need to show that care was appropriate
      3. Refusal/no-service cases
   4. Profession protection
      1. Data
      2. Quality improvement
      3. Risk management
      4. Research

2. Report writing (90 minutes)
   1. General guidelines
      1. Write clearly
      2. Be objective
      3. Be accurate
      4. If you didn't write it you didn't do it.
   2. Report formats
      1. SOAP
      2. CHART
      3. Scales - Glasgow coma, trauma, Apgar, rule of nines
   3. Special reporting
      1. Crime scene reports
      2. Incident reports
      3. Unprotected exposure reports
      4. Abuse-child, elder, disabled
   4. Western Mass EMS Run Form
      
      

Contact WMEMS:

168 Industrial Drive
Northampton, MA 01060
(413) 586-6065
fax (413) 586-0947
E-mail: wmems@wmems.org

Tax deductible donations

WMEMS is a 501c3 Non-Profit Organization that accepts tax deductible donations.

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