Documentation is one of the most important things done during and post patient care. It is your job to see that your EMS report reflects complete and accurate information, and that your patient care narrative covers more than just what the check boxes provide. Your report is a legal document and part of the patient's medical record.
With the narrative being so important, let's take a look at its contents under some different scenarios. Common pieces of information are sometimes left out.
1.) The run always starts at the time of dispatch and includes what you were dispatched to and what you found at the scene. For example: "Dispatched for a person in seizures. Upon arrival found 35-year-old female lying supine in bed in bedroom at place of residence. Complaint of chest pain." Starting out every report the same way builds consistency. This example covers what your detail was for and what you found when you got there, and also describes the position in which your patient was found and the type of distress she was exhibiting.
2.) Another common omission is information about auto accidents. A good description of the scene is required in these cases, especially with the possibility of lawsuits to follow. "Upon arrival found two-vehicle MVA, head-on collision with heavy front-end damage to both vehicles and confirmed entrapment. Vehicle found upright with interior not intact and spiderwebbing of windshield. Also found air bag deployment, no seat belt used by patient." This describes the scene and MOI, and paints a nice picture for hospital personnel. Knowing what the patient went through helps guide their care and search for further injuries.
3.) The importance of thorough documentation with patient refusals cannot be stressed enough. These have a high probability of coming back to haunt you if information is left out. "Patient was advised to be seen at medical facility and advised of the possible consequences of not being seen. Patient refused treatment and transport, and signed refusal." This protects you, showing that you asked the patient to go to the hospital and advised them what could happen if they went untreated. How many times are EMS providers called back to the scene for the same patient and find them even sicker than they were? What happens then? The family wants to know why your crew didn't take the patient to the hospital the first time. If something like this goes to court, the report must show that you asked the patient and advised them of what could happen otherwise. Don't leave out a description of the patient and their signs and symptoms; a refusal of transport is not an excuse not to write a complete narrative.
4.) Assessments: Describe your patient fully from head to toe. Beyond what was found wrong, include other signs and symptoms, even if nothing was found. Including these establishes that you were also looking for other things wrong and shows that a full secondary exam was completed. Don't forget to add comments made by the patient or any observations of actions that could be out of the ordinary. Place patient comments in quotations or prefix with Patient states. This shows the information comes from the patient and not the provider assuming something.
5.) Treatment: Document all treatments performed or attempted, even those that were unsuccessful. Remember, if it's not documented, you didn't do it! This entails medications given, procedures performed and reassurance to the patient. Yes, you should state in your report that the patient was reassured--that's a form of treatment. Remember bedside manner? It's something learned in the back of the ambulance, not any textbook. Bedside manner is a form of customer service that can give your department a black eye if not handled properly. It can be assessed by your quality assurance division through use of customer service feedback cards mailed to patients after their care. It will let you know how your customers think they're being treated and how happy they are with your service. Customer service goes a long way when a levy for emergency service funding is introduced in your community.