EMT-Basic/Assessment/Documentation

Lesson 3.8: Documentation

Objectives
By the end of this lesson, the EMT-Basic should be able to:
 * 1) Explain the components of the written report and list the information that should be included in the written report.
 * 2) Identify the various sections of the written report.
 * 3) Describe what information is required in each section of the prehospital care report and how it should be entered.
 * 4) Define the special considerations concerning patient refusal.
 * 5) Describe the legal implications associated with the written report.
 * 6) Discuss all state and/or local record-keeping and reporting requirements.
 * 7) Explain the rationale for patient care documentation.
 * 8) Explain the rationale for the EMS system gathering data.
 * 9) Explain the rationale for using medical terminology correctly.
 * 10) Explain the rationale for using an accurate and synchronous clock so that information can be used in trending.
 * 11) Complete a prehospital care report.