Patient Documentation

We have created a patient care report that is free to download and print. Please feel free to add this form to your first responder kit:

Patient Care Report Form Blank Copy

Patient documentation is a key aspect of responding as a first responder. Documentation is relevant for the purposes of legal, research, and patient handover. 

Legal:

In the case that the response and aid provided is under investigation documentation is the best legal protection. It is important to document all information objectively without subjective opinion. Always ensure you use professional language and document in timely manner to ensure you do not forget key information.

Research:

Some organization may audit patient care documentation to look for trends that may impact future care. This can help identify common injuries or illnesses responded to in a certain organization. This information can assist in furture safety recommendations for an organization or area related to call types. It can also be used to assess responder assessment and  treatment plans and guide future training to improve the organizations response to incidents.

Patient handover:

As you transfer the patient to higher levels of care the information you gathered is important to the next steps of patient care. The documentation completeness and timely handover assists the next care provider in their care plan. Verbal patient handover can easily miss key information in delivery or in retention. Written documentation assists in filling gaps in patient handover.

What should we document?

A common system used for documentation is the "SOAP" acronym. This stands for Subjective, Objective, Assessment, and Plan.

Subjective:

This includes patient demographics (name, date of birth, gender of relevance). Patient history collected from patient and/or bystanders. A great acronym to gauge the questions for patient history is the "SAMPLE" acronym. This stands for Symptoms, Allergies, Medications, Past Medical History, Last Oral Intake and Output, Events Prior to patient interaction.

Objective:

This includes your vital sign assessments and physical examination.

The vital signs you assess will depend on the responders scope of practice and access to equipment. Vital signs should be repeated throughout the patient interaction to trend changes and gauge patient condition changes (improving, getting worse, or staying the same).

Physical examination may include a detailed hands on head to toe assessment with auscultation if the patient has generalized complaints or has a decreased level of responsiveness. If the patient is alert and able to communicate their concerns a focused examination of their area of concern may be the recommended approach.

Assessment:

The assessment is what the responder perceives is the injury/illness for the patient based on their Subjective and Objective assessment. This could include specific medical condition diagnosis or generalized chief complaints (example heart attack or chest pain unknown cause).

Plan:

Based on your assessment of the patient condition the responder will come up with a plan of action. This plan will include treatments that the responder can complete on scene with the patient, vital sign and symptom reassessment and monitoring, patient disposition recommendations (ex. patient released in care of self, transported to hospital by ambulance, specialist consulted...).

Training recommendations:

Documentation is further covered into the scope of first responder training. You can seek this training by taking any of the following courses:

First Reponder

Emergency Medical Responder

Advanced First Aider

To find a course that best suits your needs check of the Red Cross link below:

https://www.redcross.ca/training-and-certification/first-aid-and-safety-courses/professional-responder-courses