Documentation, Radio Reports and Medical-Legal Issues

Prehospital Documentation and Error Correction

The prehospital care report serves multiple critical functions on every emergency response. It is a confidential legal document, an operational record of the EMS agency, and a primary tool for continuity of care as the patient transitions to the hospital staff. For these reasons, documentation must remain objective, factual, and accurate. EMTs should complete the report as soon as possible after call completion while details remain clear.

When recording information, precision protects both the patient and the provider. A patient's chief complaint should be documented as a direct quote whenever possible. Furthermore, EMTs must document pertinent negatives. These are symptoms or physical findings that are expected for a suspected condition, but which the patient denies or does not exhibit. For example, noting that a patient with chest pain denies shortness of breath provides essential clinical context.

Mistakes on reports must be handled using strict legal protocols. To correct an error on a paper patient care report, draw a single horizontal line through the error, write the correct information, and initial and date the change. Correction fluid, white-out, and total obliteration of text are strictly prohibited. In an electronic patient care report, correct errors using the system's audit-trailed correction or addendum process, which preserves the original entry while recording who made the change and when. Falsification of a patient care report constitutes gross misconduct and can lead to criminal charges and license revocation.