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

January 5, 2018 | Author: Anonymous | Category: Science, Health Science
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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.

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