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EMR
EMT
AEMT
Paramedic
Extended
Documentation
1.
An EMS report will be generated on each patient evaluated by the EMS crew. To be included are assists
when the patient is evaluated for an injury, or a medical condition is suspected.
2.
Documentation will include, but not be limited to:
a.
Initial and repeat vital signs
b.
Initial assessment, including “view from the door” and repeat vital assessments
c.
All necessary interventions and the results of those interventions
d.
Abnormal occurrences, such as a combative patient, patient condition, or location requiring extended
scene time, etc
e.
Equipment failure
f.
Chemical or physical restraint of a patient
g.
Discussion with patient that refused any or all treatment and transport
Will include:
i.
Advisement of potential consequences
ii.
Advisement of alternative medical care
iii.
Advisement to call EMS if he or she desires treatment or transport
h.
Discussion with patient that did not refuse treatment but was not transported
Will include:
i.
Alternative transportation documented, if needed
ii.
Detailed description of instructions given to patient
iii.
Advisement to call EMS if he or she desires treatment or transport
i.
When dispatched for a possible ill or injured person who states he/she did not request assistance,
document the following:
i.
The individual states he/she did not request or want assistance
ii.
Who (if known) called for assistance
iii.
The individual does not appear to need aid
iv.
The individual does not appear to be under the influence of alcohol or mind altering drugs
j.
Status of patient upon arrival at the emergency department or landing zone
k.
Bed that patient was placed in
l.
Who report was given to (name preferred)
Documentation