Title: Lesson 1-4 Documentation
Course: EMS 1119 Emergency Medical Technician > Section: Module I Preparatory

Describe the principles of medical documentation and report writing

At the end of this lesson and the associated lab activities students will be able to:

Cognitive Learning Objectives

- 1-4.1 Describe the use of written communication and documentation
- 1-4.2 Explain the legal/medical implication of the patient care report
- 1-4.3 Identify the minimum dataset reference patient information and administrative information on the patient care report
- 1-4.4 Understand how to document refusal of care, including legal implications

Affective Objectives

- 1-4.1 Explain the rationale for patient care documentation
- 1-4.2 Explain the rationale for the EMS system gathering data
- 1-4.3 Explain the rationale for using medical terminology correctly
- 1-4.4 Explain the rationale for using an accurate and synchronous clock so that information can be used in trending

Psychomotor Objectives

- 1-4.1 Complete a prehospital care report for a medical and trauma patient

Readings

- AAOS 10e, Chapter 4: pp. 106-141
- Limmer 12e, Chapter 17: pp. 393-421

Online Video Lectures

EMS Communications & Documentation by Henry Williford, IV, Adjunct Faculty EMS Programs, Southern Union State Community College, Wadley, Alabama, http://www.suscc.edu.

- Lecture 1: EMS Documentation Overview (29.09) http://www.youtube.com/watch?v=AcVUNBj7I6I
- Lecture 2: Writing Narrative and CHART Method (30.22) http://www.youtube.com/watch?v=5KtJDZdSPaw
- Lecture 3: Special Situations (13.09) http://www.youtube.com/watch?v=esj4fYNNF0Q
- Lecture 4: Patient Refusals (16.41) http://www.youtube.com/watch?v=FmZxBkoJ1Hs
- Supplemental Reading
- Documentation and Report Writing.pdf
- Medical Abbreviations.gif