Upon completion of this chapter and related course assignments, students will be able to discuss the purpose of thorough documentation of all aspects of the patient care report, including those applicable to the documentation of a patient’s refusal of care. Students will be able to explain legal implications associated with the patient care report. Students will be able to compare and contrast the handwritten report and the electronic report including composition of the narrative, standard data element collection, and other considerations specific to the type such as legibility, correction of errors, and professional presentation regarding spelling and use of medical terminology. Students will be able to recognize elements and reporting requirements for documentation of transfer of care, mass-casualty incidents, occupational exposures, and potential abuse or neglect cases.
0:00 Introduction
0:07 National EMS Education Standard Competencies
0:22 Introduction
1:55 Legal Implications of a PCR
3:26 Purposes of Documentation
4:46 EMS Research
6:36 Types of PCRs
9:09 Documentation for Every EMS Call
10:35 Transfer of Care
11:02 Care Prior to Arrival
12:08 Refusal of Care Reporting
17:58 Special Circumstances
21:20 PCR Narrative
25:59 Elements of a Properly Written Report
29:12 The Consequences of Poor Documentation
30:39 Errors and Falsification
33:59 Documenting Incident Times
