Memo - Patient Reports Being Given to Hospitals

Patient Reports Being Given to Hospitals

2009-09-23

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 . . .