At a minimum, all patient care documentation by an EMS provider shall:
Be truthful, accurate, objective, pertinent, legible, and complete with appropriate spelling, abbreviations, and grammar.
Reflect the patient’s chief complaint and a complete history or sequence of events.
Detail the assessment of the nature of the patient’s complaints.
Reflect initial physical findings, initial vital signs, abnormal findings considered important, and any significant changes.
Reflect ongoing monitoring of abnormal findings.
Summarize all assessments, interventions and the results of the interventions.
Clearly describe the circumstances and findings associated with any complex call or out-of-the-ordinary situations.
Be available in a reasonable amount of time after the patient encounter.
Remain confidential and be shared only with legally acceptable entities.
In the specific case of cardiac arrest with ROSC (Return of Spontaneous Circulation), the following are to be documented in the PCR (Patient Care Record):
Circumstances of arrest & location
Rescuer arrival time
Total duration of CPR
Initial cardiac rhythm
Initial neurological exam to include:
Pupil size & response
Level of alertness