• Exams• Documentation• Communication

IHERN• Peds

Autism• Geriatrics• Clinical Rotation• Homework assignment

DOCUMENTATION

Pre-hospital Care Report

• Computerized

direct data entry

electronic clip boards

pen based computers

PDA

Complete report while still fresh in your mind

Patient Care Reports• Become permanent part of record• Legal document• Administration

insurance and billing info• Education and research• QI

Documentation

• Confidentiality

Health Insurance Portability and Accountability Act

• Patient Refusal

Falsification• Two types of errors

OmissionCommission

actions that were wrong or improper. Document thoroughly and contact medical direction.

• If it’s not documented, it wasn’t done

• If it’s not done, don’t document it

• Repercussions

suspension or revocation of cert.

false impression of pt. care is passed on

Correcting Errors

Special situations

• Multiple-casualty incidents

use triage tags

Special situation reports• Exposure to infectious disease• Injury to self or another EMT• Hazardous or unsafe scenes of which

other crews should be alerted• Referral to Social Service agencies

remain accurate and objective