DOCUMENTATION

Emphasis on documentation has increased dramatically, paralleled by sophistication of patient care and
rise in medical litigation. Emphasis on documentation can also be attributed to increased quality
assessment/improvement, educational levels, and awareness of EMS professionals.

Documentation should be practiced just like any other technical skill. Refining a few definitions and
procedures will help avoid pitfalls, enhance the delivery of patient care, and reduce the risk of litigation.
Documentation procedures -
 Provide a record of scene information that may not be available from any other source.
 Provide continuity of care from one healthcare professional to another.
 Provide medicolegal evidence.
 Reveal any significant changes in the patient’s condition.
 Provide an internal tool for statistics, budgeting, and quality assessment/improvement.
 Reveal problems with record-keeping procedures.

Procedure

1. Collect all patient demographic information (e.g., name, age, sex, address).
2. Complete all blanks and check all pertinent boxes on the call report form.
3. Begin the narrative by documenting the patient’s level of consciousness (LOC), age, and how he or
she appears initially. “20 y.o. male found supine on living room floor, conscious and alert.”
4. Document patient’s chief complaint. This should be in the patient’s own words and included in
quotation marks, if possible.
5. Document history of present illness. This should be given in chronological sequence and should
include the time of onset, frequency, location, quantity, character of the problem, setting, and
anything that aggravates or alleviates the problem.
6. Document review systems and physical assessment findings, including any pertinent positives or
negatives. This should be a head-to-toe assessment, when indicated.
7. Document any significant past medical history, including surgeries, hospitalizations, illnesses, or
injuries.
8. Document allergies and current medications.
9. Document treatment procedures, who performed the procedures, and the patient’s response or lack
of response to treatment. Include times.
10. Document vital signs and orders, with times.
11. Attach all EKG strips documented with date, time, lead, and patient’s name.
12. Complete Glasgow Coma Scale, with times.
13. Obtain receiving nurse’s and doctor’s signature as needed.
14. Leave copy of report with patient’s chart.
DEFINITIONS

Anatomic figure, injury identification is an anterior and posterior figure located on the call report form.
It should be used to mark and label the patient’s injuries.

Chief complaint (CC) is a brief sentence or statement describing the patient’s reason for seeking medical
attention. It should be the patient’s own words if possible (e.g., “My chest hurts” or “I can’t catch my
breath”).

Demographic data include name, age, date of birth, address, occupation, and nearest relative.

History of present illness/injury (HPI) documents events or complaints associated with the patient’s
deviation from normal health. This should correlate with the reason the person is seeking medical
attention only for his or her current medical problem, not past problems (e.g., “While painting last night
around 10:00 PM, I began having this dull pain in my chest” or “I lost control of my motorcycle and
slid about 50 feet down the roadway”).

Past medical history (PMH) documents any significant past medical or traumatic illnesses that relate to
the patient’s present illness or injury. These data should include hospitalizations, surgeries, illnesses, or
injuries.

Pertinent negative is the absence of a sign or symptom that helps to substantiate or identify a patient’s
condition. For example, a patient with a suspected dislocated hip usually has decreased range of
motion; if the patient has good range of motion, this should be documented.

Pertinent positive is the presence of a sign or symptom that helps to substantiate or identify a patient’s
condition. For example, if a patient falls and complains of leg pain, an obvious bend of the midshaft
lower leg is a positive sign of injury and should be documented.

Physician orders are physician-directed advanced life support (ALS) or basic life support (BLS)
treatment orders.

Response to treatment is the patient’s response or lack of response to the care that was rendered.

Review of systems (ROS)/physical assessment are two separate categories that should be combined in the
EMS field assessment. The review of systems is a head-to-toe review of all complaints system-by-
system. The physical assessment is a head-to-toe, hands-on examination. These two should be
combined for EMS documentation into the complaints and physical findings.

Treatment is the care rendered to the patient.

ADDITIONAL DOCUMENTATION TIPS
1. Do not blacken through any documentation; draw one line through it and place your initials beside
it.
2. Use correct spelling.
3. If normal protocol or standard of care was not followed, document why.
4. Document any delays or problems responding, gaining access, or transporting the patient. Include
an explanation of the problem and the length of the delay.
5. Document any domestic problems that might have arisen.
6. Use a supplement sheet when necessary. The narrative does not have to be squeezed into a small
area on the call report form.
7. Use approved medical abbreviations.
8. Write legibly, clearly, and concisely.
9. A patient who presents with trauma and has experienced a significant mechanism of injury should
have a documented head-to-toe physical assessment, not just of areas of major complaint.
10. Complete the form as soon as possible; it enhances accuracy.
11. REMEMBER, IF IT WAS NOT DOCUMENTED, IT WAS NOT DONE!
 Documentation by Call Type

The following lists are specific pieces of information that may be necessary for complete and accurate
documentation. This information is not in prioritized order. These lists indicate suggested items that
should be included in your documentation.

Car Crash Overdose

 Patient location in auto  Level of consciousness
 Seatbelt or shoulder harness usage  Whether overdose was witnessed or not
 Loss of consciousness  Medication or substance ingested
 Velocity of accident  Amount ingested
 Type of accident (head-on, roll-over)  Time of overdose or best approximation
 Type of vehicle damage  Any associated alcohol or drug consumption
 Patient trapped or pinned  Prior overdose or suicide attempts
 Delay in extrication  Patient admission of intent to harm self
 Patient ejected from vehicle  Police notification
 Patient ambulatory at scene
Chest Pain
Coma  Activity at time of pain onset
 Sign or history of trauma  Radiation
 History of diabetes or seizure  Pain on movement
 Drug or alcohol ingestion  Onset (gradual or sudden)
 Last seen conscious by whom and when  Breath sounds (presence, quality, and
 Position found quantity)
 Scene survey  Dyspnea
 Pupils  Nausea and/or vomiting
 Response to painful or verbal stimulus  Diaphoresis
 GCS  Jugular venous distention
 Peripheral edema
Diabetes  Pain character (sharp, dull)
 Level of consciousness For any pain, PQRST format can be used
 Insulin-dependent or oral hypoglycemics  Pain on scale 1-10
 Last meal
 Amount of exercise Gunshot wound
 Last insulin injection and how much  Number of wounds
 Any recent illnesses  Location of wounds
 Gradual or rapid onset of symptoms  Type of weapon (handgun, rifle, or shotgun)
 Kussmaul breathing  Patient’s position at time of shooting
 Alcohol or other drug use  Perpetrator’s position at time of shooting
 How many shots heard
Trauma  Head-to-toe assessment
 Level of consciousness  Note caliber of weapon, if it can be
 Type of accident confirmed
 Ambulatory after accident  Amount of external hemorrhage noted
 Head-to-toe assessment  Police notification
 Special circumstances
 Scene survey

No transport call
 Clear documentation  Level of consciousness
 Patient demographic information  History of seizures
 Patient informed of consequences of not  History of alcohol or other drug usage
being transported  History of diabetes
 Methods used to encourage patient to accept  Sign or history of injury
treatment/transportation  Number of seizures
 Alcohol or other drug usage  Duration of seizures
 Level of consciousness  Motor activity observed during seizure (e.g.,
 Patient’s reason for contacting EMS where began and spread)
 Individual responsible for contacting EMS,  Medication history (i.e., takes seizure or
if not the patient diabetic medications regularly)
 Vital signs  Pupils
 Physical exam  Breath sounds
 Cancellation en route noted (e.g., police,  Head-to-toe assessment
fire, dispatch)  Cardiac history
 Patient’s cooperation with your attempt to
deliver care and transport Pregnancy
 Signature of patient  Last menstrual period
 Signature of witnesses  Estimated due date (if known)
 Number of pregnancies (gravida)
Pediatric  Number of pregnancies carried to term
 Level of consciousness (crying, (para)
uninterested)  Prenatal care history (none, some,
 Parent recognition continuous)
 Consolable  Complications with this pregnancy
 Fontanelles (full, flat, or sunken)  Complications with other pregnancies
 Child’s weight  Water broke
 Skin condition  Back pain
 Finger grasp  Urge to push
 Response to pain  Vaginal discharge
 Fever  Multiple births
 Length of illness  Type of pain
 Medications or treatments administered  Duration of pain
 Regularity of pain
Respiratory distress  Interval between pains
 Level of consciousness  Progress during transport
 Skin color and temperature
 Amount of distress (mild, moderate, or Stab wounds
severe)  Number of wounds
 Audible respiratory sounds (wheezes, rales,  Location of wounds
rhonchi)  Amount of external hemorrhage noted
 Onset of distress (gradual or sudden)  Patient’s position at time of stabbing
 Activity at time of onset  Perpetrator’s position and knife angle at
 Cardiac history time of stabbing
 COPD history  Head-to-toe assessment
Breath sounds (present, absent, wheezes, rales)  Scene survey & Police notification

Seizure
Documentation Checklist

Procedure Possible Points

points awarded
Obtain demographic information 1
Clearly define chief complaint 1
Note initial level of consciousness 1
Define location/presentation 1
Obtain history of present illness 1
Perform complete physical assessment 1
Note pertinent positives 1
Note pertinent negatives 1
Note pertinent past medical history 1
Document allergies 1
List current medications 1
Record treatment 1
Record response to treatment 1
Place EKG strip. (ALS services only) 1
Document orders 1
Document times 1
Record vital signs 1
Complete Glasgow Coma Scale 1
Completed Trauma Score (if indicated) 1
Obtain appropriate signatures at receiving facility 1

Total 20
Points

COMMENTS:____________________________________________________________

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