EMT Curriculum

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)

▪ 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)