How Do You Document?

[Richard B the EMT]

If both a BLS and ALS crew treat, no matter who actually transports, both crews fill out call reports, and both are supposed to have the report number, as well as the radio identifier, from the other unit.

Our ePCRs are all individually numbered by the company that manufactures them, and each call has an assignment number on it from the Computer Assisted Dispatch system.

[Arkymedic]

I'm finishing my last year in school and currently we're focusing heavily on documentation. I was wondering how everyone here documents their ALS calls? Specifically, I'd like to see how you do a review of systems within a SOAP (SOAPIE) format. It is something that many people do, but I've never been instructed on.

I'm just intersted to see how different ALS providers document. Please feel free to give examples.

Thanks.

I-Incident

C-Chief Complaint

H- Hx and Allergies

A- Assessment

R- Rx and Rx

T- Transportation

Incident- How and what I was dispatched on, agencies on scene, what I found.

C/C- What pt and bystanders say is going on

Hx and Allergies- Med Hx and recent hx of illness or injury, allergies

Assessment- head to toe physical

Rx and Tx- self explainatory

Transport- How pt was moved, where the pt was taken emergent or non, if condition changed enroute, arrival @ facility, how pt was moved, who took report and that care was transferred, and that pt was without further complaint or pain upon transfer of care.

Name Title State EMS #