Memo - Patient Reports Being Given to Hospitals

From Protocopedia
Jump to navigation Jump to search

Patient Reports Being Given to Hospitals


As a reminder . . . and effective immediately . . .

Per State Statute . . .a patient report MUST be left at the hospital when you transport a patient.

These reports are read by the hospitals, are necessary for hospitals to pass audits, and, most importantly, can affect patient care…therefore

Per Quality of Care Standards: They Are Necessary!...and the more thorough the better.

  • Which means, if you don’t leave a thorough report, you are not providing quality care.
  • Which means, you shouldn’t be endangering patients under my license.

The report MUST contain:

  • ALL pertinent positive and pertinent negative information in narrative form on your patient
    • You do not need to write full sentences . . . a list will do
    • History
    • Physical
    • What your thoughts were, what you did and the outcome
  • It must be necessarily detailed and thorough; complete and accurate
  • ALL meds given must be listed
  • ALL vitals taken must be listed
  • ALL times for meds given and vitals taken must be listed

Remember . . . your documentation is 50% of what kind of medic you are . . .