DOCUMENTATION
Thorough documentation of every patient encounter is necessary. The form that documentation takes will vary with the type of encounter. In all situations where a patient is assessed by a paramedic for psychological or medical disorders and undergoes a history and physical examination a PCR should be completed.
The following are a guideline for what should be included in that PCR.
1. History of the present illness and/or origins of the present crisis.
2. Past psychological and medical history including current medications and therapy.
3. Compliance with therapy and medications.
4. Allergies.
5. Vital Signs.
6. Any Point of Care testing including BGL and Breathalyzer results.
7. Physical examination (head-to-toe) if allowed by patient.
8. Field diagnosis or assessment.
9. Treatment recommendations and disposition decisions.
In cases where the patient will not be transported or taken to an appropriate facility or office a Refusal Form is not always required. A Refusal Form should be completed along with a complete PCR when the patient is not willing to follow through on treatment recommendations.
Thorough documentation of every patient encounter is necessary. The form that documentation takes will vary with the type of encounter. In all situations where a patient is assessed by a paramedic for psychological or medical disorders and undergoes a history and physical examination a PCR should be completed.
The following are a guideline for what should be included in that PCR.
1. History of the present illness and/or origins of the present crisis.
2. Past psychological and medical history including current medications and therapy.
3. Compliance with therapy and medications.
4. Allergies.
5. Vital Signs.
6. Any Point of Care testing including BGL and Breathalyzer results.
7. Physical examination (head-to-toe) if allowed by patient.
8. Field diagnosis or assessment.
9. Treatment recommendations and disposition decisions.
In cases where the patient will not be transported or taken to an appropriate facility or office a Refusal Form is not always required. A Refusal Form should be completed along with a complete PCR when the patient is not willing to follow through on treatment recommendations.