I'm an EMT and a med student on rotations. Question about EMT documentation.

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So, I feel a little conflicted when I write up EMS PCRs. I've always tried to write the tripsheets in accordance with what I learned in EMT school, but I'm now wondering if I should document things that I've learned to identify in med school.

For example, if the patient has decorticate posturing, is it wrong to document that in my EMS PCR? It's certainly not something I've learned to identify in EMT school, but I know it from med school. I run into similar problems on abdominal and cardiovascular exams, where I've learned a lot beyond the EMT scope of practice.

It's just really hard to use 2 completely different documentation styles depending on where I'm working. Would I run into any trouble if I just started writing EMS PCRs like a SOAP note on the wards?

Thanks a bunch.
 
Decorticate posturing should have been taught in your emt basic class.

As long as you follow your services policy for report writing and you do not exceed your protocol no problem noting your findings. And many services use SOAP.
 
No. I foresee no trouble for you if you document what you find. There's no limit on what you assess on your patients, and the best way to communicate that to the people who come after you who may read your report is to clearly document it.

Having done both, I find that I prefer the CHART method more appropriate for EMS than SOAP, but it really is a matter of preference, IMO.
 
First... document in the style your agency requires.



As for what is and is not within your "scope" of what you learned, that's a null point. We aren't limited in knowledge to only what we learned in school. We are forever learning.

If you see it and know what it is, you can document it. The trouble comes in to something you CAN'T say, such as "They were drunk" or an EMT interpreting an EKG.
 
Wow thanks for all the responses!
 
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I don't see why it would be a problem provided that the exam information is done with the tools normally available. There's a big difference between documenting a fundoscope exam and documenting, say, acanthosis nigricans.

As far as SOAP style, provided you've included enough information in it (I would include a prearrival section before S and a reevaluation section after P), I don't see why it would be a problem.


On a side note, using the California scope of practice as an example (which is where I am at), I do kinda of wonder how far I could stretch the unqualified terms "Evaluate the ill and injured" and "Obtain diagnostic signs to include, but not be limited to, the assessment of temperature, blood pressure, pulse and respiration rates, level of consciousness, and pupil status." Emphasis added.:D Conceivable, I could justify 12 leads (which, of course, I'd lack the equipment), or fundoscope exams (required to own an ophthalmoscope and otoscope for school) under the pure letter of the law.
 
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Document at your knowlege level but do not treat beyind your scope. This is a legal document. You may be a doctor when you get called into court. You need to know what your talking about.
 
Remember if called to court your report is being read by the people that were not clever enough to escape jury duty so keep that in mind as well.
 
medic417 said:
Remember if called to court your report is being read by the people that were not clever enough to escape jury duty so keep that in mind as well.
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Nobly chose to do their duty to society so that others would not be so unfortunate...
 
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