Lesson 3.8: Documentation
By the end of this lesson, the EMT-Basic should be able to:
- Explain the components of the written report and list the information that should be included in the written report.
- Identify the various sections of the written report.
- Describe what information is required in each section of the prehospital care report and how it should be entered.
- Define the special considerations concerning patient refusal.
- Describe the legal implications associated with the written report.
- Discuss all state and/or local record-keeping and reporting requirements.
- Explain the rationale for patient care documentation.
- Explain the rationale for the EMS system gathering data.
- Explain the rationale for using medical terminology correctly.
- Explain the rationale for using an accurate and synchronous clock so that information can be used in trending.
- Complete a prehospital care report.