EMT Lesson Plans

Chapter 4: Communications and Documentation

National EMS Education Standard Competencies

Preparatory

Applies fundamental knowledge of the emergency medical services (EMS) system, safety/well-being of the emergency medical

technician (EMT), and medical/legal and ethical issues to the provision of emergency care.

Documentation

Recording patient findings (pp 119 – 126)

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 Principles of medical documentation and report writing (pp 119 – 126)

Knowledge Objectives

1. Describe the use of written communication and documentation. (pp 119 – 126) 2. Identify the information required in a patient care report (PCR). (pp 119 – 123) 3. Explain the legal implications of the patient care report. (pp 119, 123 – 125) 4. Understand how to document refusal of care, including the legal implications. (pp 124 – 125)

5. Discuss state and/or local special reporting requirements, such as for gunshot wounds, dog bites, and abuse. (p 125)