Report Writing and Preparation For Next Call

OBJECTIVES

Upon completion of this lesson, you will be able to:

1. Demonstrate how to record information about the patient’s condition and treatment given on the prescribed form.
2. List five steps to decontaminate the transport vehicle.
3. List four steps to decontaminate the stretcher.
4. List three steps to decontaminate instruments.
5. List the three items for personal decontamination.

1. Report Writing

Documentation is extremely important and may be legally required for patient care rendered by the MFR. A properly completed written report not only provides all the pertinent facts; it also provides them in a logical order.

Pre-hospital Treatment Report

A pre-hospital treatment report is used for all the following reasons:

• To transfer patient information from one person to another.
  Your report is turned over to the personnel who transport your patient. They will, in turn, give it to the hospital staff who use it to learn the patient’s history, including the condition in which he/she was found, what emergency care was provided, and how the patient responded to that care.
• To provide legal documentation.
  A written report prepared at the scene of an emergency may be used as an official record. If you provide care at the scene of an injury or act of violence, for example, your report may become evidence in the court proceedings.
• To document the care you provided.
  This is important for official reasons, as well. Unfortunately, patients and their families sometimes sue first responders and other EMS professionals. Accurate documentation can be one of your best defenses against legal or official action.
• To improve your EMS system.
  Research is performed in many different areas of your EMS system. It is used to improve such factors as response time and the effectiveness of certain procedures. Accurate reports are vital to that research.

Always take official report forms to document the patient’s information and gather data in the standard format.

You should record the following basic data:

• Patient Information: Name, age, gender, and any identification available.
• Incident Details: Date, time, and location of the emergency.
• Chief Complaint: Patient’s primary reason for seeking medical assistance.
• Patient’s Condition: Vital signs such as pulse, blood pressure, respiratory rate, and level of consciousness.
• History: Medical history, allergies, medications, and any recent illnesses or injuries.
• Treatment Provided: Details of the emergency care administered at the scene.
• Patient’s Response: How the patient reacted to the care provided.
• Additional Observations: Any notable factors or environmental details that may be relevant.

2. Decontamination of the Unit, Equipment, and Personnel

2.1 Transport Unit (Ambulance or other)

After completing a call, the transport unit should be prepared to be available to respond to the next call. Complete these steps:

1. Dispose of all contaminated supplies (bandages, dressings, disposable materials) in a sealed plastic bag.
2. Collect all contaminated reusable equipment and seal them in another plastic bag.
3. Clean the floor, walls, and ceiling with soap and water. They may be contaminated with blood, vomitus, fecal matter, dust, mud, etc.

4. Disinfect surfaces with a solution of water and 10 percent bleach. This solution may be harmful to bright metal surfaces.
5. Air out the ambulance.

2.2 Decontamination of the Stretcher

1. Remove the contaminated sheet.
2. Clean and disinfect the stretcher mattress.
3. Turn the mattress.
4. Place a clean sheet on the mattress.

2.3 Decontamination of Instruments

1. Scrub contaminated instruments to eliminate any debris, then wash them with soap and water.
2. Soak instruments in a 10% bleach and water solution for ___ minutes, then dry them off.
3. Replace instruments and any medication on the unit.

3. Personal Decontamination

Make sure to decontaminate the following three items after every incident:

• Hands: Thoroughly wash hands in soap and water. Pay close attention to the fingernails, between the fingers, and the wrists.
• Clothes: Change out of any contaminated clothing and immediately wash separately from other linens. Keep a spare change of clothes available.
• Shoes: Wipe shoes clean. Wash off all bodily fluids with a 10% bleach solution.

4. Material Consumption Report

All the teams proceeding for rescue must file in a Material Consumption Report on their return. This should include consumed and damaged items, and it will help in:

• Maintaining record of all items which have been consumed.
• Early replenishment of the items, so that there is no shortage of life-saving equipment with the team, and they are again ready for taking on their responsibilities in a befitting manner.

Final Report Format (Sample)

Material Consumption Report

Reference: _______ Incident no.: _______ Date: _______

Unit: _______ Station: _______

Team Members Name:

1. ---

2. ---

3. ---

4. ---

5. ---

6. ---

Nature of Emergency: ___________________________

No. of Patients: ___________________

S. No	Items Consumed	Quantity	Consumable/Non-Consumable	Replenished (Yes/No)

Signature of Unit In Charge: ___________________________

Signature of Station In Charge: ___________________________