Transcript Report Writing (Powerpoint) - Volusia County Fire Chiefs` Association

Report Writing
EMS and Fire Reports
Why do we write reports?
• Medical documentation
• Administrative
information
• Research
• Legal
– Attorneys will have access
to YOUR report in a legal
preceding
Patient Care Reports
• A well written PCR is
accurate, legible, timely,
unaltered and
professional.
• Volusia County Protocols
require a PCR be
completed to include the
data in a SOAPP format.
SOAPP FORMAT
• Subjective
– Chief Complaint
– History of present
illness (including
history of events
surrounding the call)
– Past medical history
SOAPP FORMAT
• Objective
– Vital signs
(normal/abnormal)
– General impression/
physical findings
(normal/abnormal in
relation to the chief
complaint)
SOAPP FORMAT
• Assessment
– Working diagnosis and it
can be the same as the
chief complaint.
SOAPP FORMAT
• Plan
– Protocol(s) followed
• Intubations (all airways),
IV’s, I/O’s need to document
number of attempts
– Physicians orders
• Include the name of the
physician giving the order.
SOAPP FORMAT
• Prehospital Course
– Assessment / management
performed and how did the
patient respond.
– This may be short if patient
care is transferred quickly
Reports
• Cardiac Alerts / Stroke alerts
/Trauma Alert criteria sheets
will need to be attached to
the hard copy PCR.
– Additionally, the new Cardiac
Alert protocols will address
STEMI alerts (ST elevation in an
MI)
• Patient refusals need to
documented and the PCR
forwarded to administration.
PCR - Refusals
• Refusals shall receive
complete documentation
on the hard copy.
– Refusal witness shall be
from another agency (i.e.
LEO, EVAC)
• Electronic reports for
refusal shall be in the
SOAPP context .
PCR - Refusals
• Documentation should include the
following:
– Thorough assessment
– Patient competency (alert & oriented x
4)
– Your recommendation for care and
transport
– Explanation you gave to the patient in
reference to consequences of
refusing up to and including death
– Patient’s understanding of your
statements
– Advising patient you will return if they
change their mind
PCR – EVAC assists
• PCR shall include the
following:
– What you were dispatched
to .
– What you found upon
arrival. (EVAC conducting
pt. assessment / pt. loaded
for transport / Care
assistance provided)
– Prehospital course your
unit provided.
PCR – Patient Assists
• What your unit was
dispatched to.
• What you found upon
arrival.
• What course of action
you took (vitals, assist to
bed, ect.)
PCR – Cancelled Prior to Arrival
• Dispatch information
• Reason for cancellation
– Time of cancellation, who
cancelled your agency.
Documentation
• Just hitting the autogenerate button on
Firehouse does not
complete your report
responsibilities.
• Remember that poor,
incomplete or inaccurate
documentation can be
costly in a lawsuit both to
you and your agency.
Fire Reports
• Like a PCR, proper
documentation of all
dispatched calls is an
essential requirement of
your job.
Required NIFRS Information
•
•
•
•
Location
Date
Times
Apparatus /
Personnel
responding
• Incident type
• Property type
• Resident /
Owner
• Level / area of
origin
• Information
about the
structure and
presence of
protection
systems
• Damage / loss
information
Narrative
• Dispatch information
– Turnout times greater than 60
sec. will require documentation
in NIFRS
• Causes can include in training/
apparatus checks/pre-plans &
inspection/ immediately enroute
time inaccurate, ect.
– Delays will require
documentation in NIFRS
• Traffic / wrong address / train /
security gates, ect.
• Any time greater than a 30 sec.
delay will be documented.
Narrative
• Arrival / Size-up
information
• Command
• Assignments
– Mode, Attack, Water
supply, Utilities, Search,
RIT, Ventilation, Rehab,
ect.
Narrative
• Thermal Imager use
• Special or unusual actions
including deviating from SOP’s
• Injuries or death (in addition,
complete the appropriate NFIRS)
• Investigation results (note when
the Fire Marshal or PD is
investigating further)
• Any damaged or broken
equipment (may be an addendum)
Narrative – False Alarms
• Dispatch information
• Arrival information
• Disposition (what you
found)
• Facility member or
homeowner you made
contact with to confirm
the false alarm.
Narrative – Cancelled Enroute
• Dispatch Information
• Reason for cancellation
• Name of the person who
cancelled the Fire
Department
Practical Assignments
• Using the SOAPP method
complete a written PCR
narrative for the EMS
information given.
• Complete a narrative for
the information given for
a fire report.
References
• Volusia County Medical
Protocols
• Bledsoe, Cherry, Porter
(2003), Essentials of
Paramedic Care, Brady;
Upper saddle River, NJ
• IFSTA (2001), Fire
Department Company
Officer; Third Edition,
Stillwater, OK.