Exams Documentation Communication IHERN Peds Autism Geriatrics Clinical Rotation Homework assignment

DOCUMENTATION

Pre-hospital Care Report Computerized direct data entry electronic clip boards pen based computers PDA

Complete report while still fresh in your mind

Patient Care Reports Become permanent part of record Legal document Administration insurance and billing info Education and research QI

Documentation Confidentiality Health Insurance Portability and Accountability Act Patient Refusal

Falsification Two types of errors Omission Commission actions that were wrong or improper. Document thoroughly and contact medical direction.

If its not documented, it wasnt done If its not done, dont document it Repercussions suspension or revocation of cert. false impression of pt. care is passed on

Correcting Errors

Special situations Multiple-casualty incidents use triage tags

Special situation reports Exposure to infectious disease Injury to self or another EMT Hazardous or unsafe scenes of which other crews should be alerted Referral to Social Service agencies remain accurate and objective