Over the years, prehospital documentation has become more complex. From paper charting to basic electronic patient care reports to complex systems that automatically report to the state and perform quality improvement reports, the amount of documentation required on a run has increased. Medical documentation has become as important a skill for a prehospital provider to learn as operating a monitor or assessing a patient, yet the time spent learning the foundation and nuances of medical documentation is a one-chapter lecture in school. Often, preceptors do not provide much feedback on run reports and although, from an administrative perspective, documentation is of high importance that importance is often minimized in the field. In this talk, the presenters will discuss basic documentation pearls and pitfalls and how they apply to high-risk scenarios such as the agitated patient and refusals using real-life scenarios.
Michael Halloran - Senior Assistant City Attorney, Columbus City Attorney Zach Klein’s Office