Documentation in EMS
EMS Documentation serves as a vital clinical purpose. It is a record of your assessment and care of the patient. It becomes part of the patient's medical record, both at the receiving facility and within your organization. EMS PCRs record the role EMS providers play in the continuum of care for each and every patient. An accurate record of the care provided in the field plays a crucial role in the subsequent treatment of patients in an emergency department, trauma center or any other receiving facility. An effective EMS chart informs subsequent caregivers of the patient's presenting signs and symptoms, the assessment provided by the EMT, interventions attempted and the patient's response to those interventions. PCRs are clinical documents, thus it is extremely important for EMS to furnish this documentation at the point of care handoff. As we all know, if it is not written down, it did not happen!!
This course is intended for those licensed at the EMR level through Paramedic. This course satisfies the requirements for the State of Wisconsin EMT Flexible Refresher Renewal.
- Know what constitutes a report
- Understand who might/will be reading the report
- Understand what time frame EMS has to complete the report
- Understand the appropriate terminology to be utilized as well as abbreviations
- Know that every patient care report should include objective information, subjective information and details relating to the care provided to the patient
- If the information was not entered in the PCR, but an EMT says it was completed, it truly never happened in the eyes of a legal team/judge.
EMT-First Responder - 2.0 hours (Documentation and/or flexible content)
EMT-Basic - 2.0 hours (Patient Assessment and/or flexible content)
AEMT - 2.0 hours(Flexible Content)
Paramedic - 2.0 hours (Flexible Content)
- 2.00 AttendanceAttendance Credit