Many emergency responders including Lifeguards, complete a patient care report on the incidents they respond to. Responders involved in the incident need to complete the appropriate report form as quickly as possible after providing care. Record only factual information of what was heard and seen and any action taken. Do not give personal opinions.
Documentation is important for legal reasons as well as for tracking when, where and how often incidents occur. Reports provide valuable information for facilities to use when they assess safety protocols, such as staffing levels or placement of lifeguard stations.
Here is a checklist of questions providers should answer before submitting a report:
- Are your descriptions detailed enough?
- Are the abbreviations you used appropriate and professional?
- Is your report free of grammar and spelling errors?
- Is it legible?
- Is the chief complaint correct?
- Is your impression specific enough?
- Are all other details in order?
1. Check descriptions
Upon the completion of every incident, your report documents all events that occurred. This includes a detailed assessment of the situation and a full recounting of the treatment administered to the patient. It is specific, informative, free of ambiguity and negligence.
- Which arm is the patient having pain?
- Is it the upper or lower part of the arm?
- What was the timeline of the incident?
2. Check (and recheck) spelling and grammar
Your report should paint a picture, but this is impossible to do without proper English. Besides not being accurate or professional, incorrect English may very well lead a reader to believe something false. For example, there may be confusion (and laughter) if a report says “patient fainted and her eyes rolled around the room.” Though this is a humorous example, dire consequence can follow confusing reporting.
Reporting should be free of misspellings and the understanding of what you are trying to say should be clear. For example, the trauma surgeon should have a good understanding of the mechanism of injury that brought the patient to the hospital from reading your report.
3. Assess your chief complaint description
An area of the report that is frequently misused is the chief complaint which should explain why you were needed or why the patient is being treated. Chief complaint is not the cause of the injury. For example, a chief complaint is pain to the right lower arm, not the fact that the patient has fallen off a ladder. Using the patient’s own words is an appropriate practice if they describe symptoms of their chief complaint.
4. Review your impressions
An impression encompasses the reasons for patient treatment. Trauma and fall are too vague to be used as impressions. Include the body areas or symptoms that are being treated. In other words, what treatment protocol is being followed?
If you are following a stroke protocol, and your assessment indicates a possible stroke, this should be included in your impression. Multi-systems trauma injuries bring additional challenges, but if multi-body systems are involved, they all should be included in your impression of the patient.
5. Check the final details
The patient’s SAMPLE including past medical history and medications are important to note. Document the patient’s history completely. Remember bystanders or those close to the patient can often provide valuable information about the patient.
Another important aspect to clearly document is the outcome of your treatments. Some reports have a standard text box that indicates improved, but in your narrative you should clearly document how the treatment improved the patient’s condition.
After the incident and upon completion of the report writing, you may be asked to attend an operational debriefing. The goals of the debriefing are to examine what happened, assess the effectiveness of the EAP, condier new ways to prevent similiar incidents and to be alert for stress reactions after a critical incident. Be sure to avaoid assigning blame or criticizing anyone’s actions or reactions.
For additional in-service training at your facility, contact the rescue professionals at Safety Training Pros 844-900-SAFE (7233).
