Volume 2 Chapter 6

The written record of and EMS response

• Medical
• Administrative
• Research
• Legal

Time elapsed from when a unit is alerted to when it arrives on scene

Scannable run sheet on which you fill in boxes or bubbles to record assessment and care information

• Appropriate medical terminology
• Correct abbreviations and acronyms
• Accurate, consistent times
• Thoroughly documented communications
• Pertinent negatives
• Relevant oral statements of witnesses, bystanders and patient
• Complete identification of all additional resources and personnel

• Complete
• Accurate
• Legible
• Timely
• Without alterations
• Professional

Addition or supplement to the original report

Language used by a particular group or profession

Writing false and malicious words intended to damage a person's character

Speaking false and malicious words intended to damage a person's character

• Head to toe
• Body systems

What you believe to be your patient's problem based on your history and physical exam

• SOAP
• CHART
• Patient management
• Call incident

• Subjective
• Objective
• Assessment
• Plan

• Chief complaint
• History
• Assessment
• Rx(treatment)
• Transport

Your patient refuses care even though you feel he needs it

Tags containing vital information affixed to your patient during an MCI