General Guidelines

    The following guidelines must be followed on all documentation:

• Write neatly in black or blue ink.

• Use military time.  For example, "1630" for 4:30 p.m.

• Draw a single line through all errors and place your initials near each one.

• It is both a medical and legal assumption that if something is not documented, it did not happen!

 Shift Report

    The shift report is a logistical report completed by an EMT for each shift of IU-EMS' coverage of an event.

 It details event information, the arrival and departure times of assigned IU-EMS members, and member

 training provided, among other things.  A sample image and a corresponding explanation will be posted

 following revision of the shift report.

 Equipment Checklist

    The equipment checklist is a logistical checklist completed by an EMT prior to each shift of IU-EMS'

 coverage of an event.  It records the confirmation of the presence and proper functioning of all standard

 IU-EMS equipment and supplies.  A sample image and a corresponding explanation will be posted following

 revision of the equipment checklist.

 First Aid Report

    All first aid treatment must be properly recorded on the first aid report according to the given example and

 the following guidelines:

• All columns must be completed for each patient.

• The date must be written in American format:  Month/Day/Year.  For example, "04/12/08."

• Remember to use military time.  For example, "1630."

• Ensure that the patient's name is spelled correctly.

• All First Aiders that rendered assessment and treatment for each patient must sign their names under the "First Aider(s)" column.

• Use multiple rows for a single patient if necessary.  Only extend the complaint, the treatment, and the First Aider(s) to subsequent rows.

• Complete all rows on each first aid report sheet before using a new one.  Each first aid report sheet will contain multiple dates and events.

A blank practice version of the IU-EMS first aid report can be downloaded by clicking on the below button:

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 Patient Report

   The patient report is the most important document that IU-EMS members complete.  It serves as a full

 medical and legal record of any and all patient assessment and treatment rendered by EMTs.   EMTs must

 assess and treat all patients who present with signs or symptoms beyond the First Aider scope of practice.

 Furthermore, EMTs must fully complete a patient report for all of their patients.

    The first two pages, which are printed on the front and back of a single sheet, are required.  The third page,

 the narration continuation page, is only necessary if the primary EMT is unable to complete his or her

 narrative utilizing the space given on the first page.

    Below is a color-coded version of the IU-EMS patient report with a thorough explanation of each item.  This

 coded version, as well as a completed sample version and a blank version for practice, can be downloaded

 by clicking on the appropriate below buttons.  If you are unfamiliar with the abbreviations used in the sample

 patient report, see the IU-EMS abbreviations page.

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 ► Color Key

         The color of each section on the coded version of the patient report indicates who can complete the

      items in that section.  No one can complete any section of the patient report without the authorization of

      the patient's primary EMT.  Never complete any item on the patient report without the authorization of the

      primary EMT.

• Purple:  Only the patient's primary EMT can complete items in this section.  The primary EMT carries full medical and legal responsibility for all assessment and treatment of the patient and all information recorded on the patient report.

• Blue:  Only EMTs can complete items in this section.  The primary EMT or an assisting EMT (with the authorization of the primary EMT) can complete items in this section.

• Green:  Either an EMT or a First Aider can complete items in this section.  The primary EMT or an assisting EMT or a First Aider (with the authorization of the primary EMT) can complete items in this section.  First Aiders can only write what an EMT precisely directs them to write.  A First Aider can never complete any item on the patient report by themselves.

• Gray:  Only the patient can complete this section.

 ► Section 1:  Event & Time Information

• Organization:  The organization that is hosting the event and which hired IU-EMS to provide coverage at that event.  For example, "IUDM" or "IUSF."

• Event:  The name of the particular event.  For example, "Dance Marathon," "5K Walk/Run," or "Little 500 Practice."

• Location:  The location of the event.  For example, "HPER" or "Bill Armstrong Stadium."

• Date:  The date in American format:  Month/Day/Year.  For example, "04/12/08."

• Time of Onset:  The time the patient became ill or was injured.  This will usually not be evident until an EMT obtains a SAMPLE history from the patient.  Remember to use military time.  For example, "1630."

• Time Notified:  The time IU-EMS noticed the patient was in need or someone notified IU-EMS.

• Time of Arrival:  The time IU-EMS initiated patient assessment and treatment.

• In Service:  The time IU-EMS completely finished with the patient situation, including cleaning the patient area, restocking used equipment and supplies, and completing the patient report.

 ► Section 2:  Patient Demographic Information

         Although this section is located at the top of the page, you do not have to complete it at the beginning of

      your patient assessment and treatment.  It is recommended to complete the patient assessment and

      treatment first, then complete the patient demographic information section prior to releasing the patient.

      This will prevent the patient from receiving the impression that you are more concerned about his or her

      demographic information than his or her illness or injury.  However, if the patient is anxious or frightened,

      you may wish to complete this section first in order to establish rapport with and calm the patient.  This is

      especially true with pediatric patients.

• Name and Guardian:  The patient's full legal name, with the last name first.  For example, "Kenedy, Beth A."  If the patient is under 18 years of age, the name of a parent or legal guardian must also          be recorded.

• Gender:  The patient's biological sex (what he or she was born as).  Biological sex has more medical significance than gender identity.

• Age:  The patient's current age in years.

• DOB:  The patient's date of birth in American format:  Month/Day/Year.  For example, "07/04/86."

• Local Address:  The patient's full Bloomington area address, including street name and number, apartment or room number, city, state, and zip code.

• Local Phone Number:  The patient's local residence phone number or cell phone number, including area code.

• Permanent Address:  The patient's full permanent address, including street name and number, apartment or room number, city, state, and zip code.  If the patient's local address is his or her permanent address, write "Same."

• Permanent Phone Number:  The patient's permanent residence phone number or cell phone number, including area code.  If it is the same as the patient's local phone number, write "Same."

• SID/SSN:  The patient's 10-digit student ID number if he or she is a current IU student.  For example, "0001231234."  If the patient is not a current IU student, record his or her social security number.  For example, "123-456-1234."

• Network ID/E-mail Address:  The patient's network ID if he or she is a current IU student.  This is the first portion of his or her IU e-mail address.  For example, "bakennedy."  If the patient is not a current IU student, record his or her full e-mail address if available.  For example, "bkennedy4@hotmail.com."

• Race/Ethnicity:  The patient's biological race (skin color), not ethnic or cultural identity.  Biological  race has more medical significance than ethnic or cultural identity.  If unsure, ask; do not guess!  If the patient states  he or she is multiracial, indicate all of his or her races.

• Physician's Name:  The patient's primary care physician.  This will almost always be his or her general practice (family) physician or pediatrician.  Record both the first and last name if available.  Otherwise, the last name only is sufficient.

 ► Section 3:  Chief Complaint

         The patient's primary presenting illness or injury.  Only the primary EMT can complete this item.  If the

      patient is not fully oriented, the EMT can dictate the chief complaint based on his or her patient

      assessment findings.

 ► Section 4:  Vital Signs

• Time:  The time you began taking that specific set of vital signs.  Remember to use military time.  For example, "1630."

• LOC:  The patient's level of consciousness.  If the patient is awake, this will be "A&OX" followed by the number of orientation questions he or she is able to answer (out of person, place, and time).  If the patient is not awake, the LOC will be the corresponding level on the AVPU scale.  The following are the seven possible items to write in this box, from most oriented to least responsive:

  • A&OX3:  Patient correctly answers all three orientation questions.

  • A&OX2:  Patient correctly answers two of the three orientation questions.

  • A&OX1:  Patient correctly answers one of the three orientation questions.

  • A&OX0:  Patient is awake but unable to correctly answer any of the three orientation questions.

  • V:  Patient is responsive only to verbal stimuli.

  • P:  Patient is responsive only to painful stimuli.

  • U:  Patient is completely unresponsive to all stimuli.

• Respiratory Rate:  The patient's rate of breathing.  Remember to multiply correctly so that you record it as respirations per minute.

• Breath Sounds:  The patient's breath sounds in each lung as he or she inhales and exhales.  Circle "L" for the patient's left lung and "R" for his or her right lung next to the appropriate description(s).

• Pulse Rate:  The patient's heartbeat rate.  Remember to multiple correctly so that you record it in beats per minute.

• Oxygen Saturation (SpO²):  The patient's blood oxygen saturation.  IU-EMS does not currently carry pulse oximeters, so this box will always be marked with an "X," a slash, or an "N/A."

• B/P:  The patient's blood pressure.  It is written in fraction format, with the systolic (higher) number  above and the diastolic (lower) number below.  Remember to write "P" below the fraction line if you take the blood pressure by palpation.

 ► Section 5:  Diagnostic Signs

• Pupils:  The responsiveness of the patient's pupils to a concentrated light stimulus, such as a penlight.  PERRL means "pupils equal, round, and reactive to light," and is the standard condition.  If the eyes are not PERRL, record all conditions present in either eye.

• Sensation/Movement (CSM):  The patient's ability to move each of his or her extremities and to feel external stimuli on each one.

• Skin:  The patient's skin color, temperature, and moisture.  Warm, pink, and dry are the standard conditions.  Capillary refill time is the time it takes for circulation to return to a pinched finger or toe.  Less than two seconds is standard.

 ► Section 6:  Medications & Allergies

• Medications:  The patient's prescription medications, as well as any OTC (over-the-counter) medications or illicit drugs that he or she has recently used.

• Allergies:  The patient's allergies to medications, food, and environmental pathogens.

 ► Section 7:  Medical History

         The patient's past and current medical history.  Record any conditions that he or she has had in the past

      or currently has. 

 ► Section 8:  Trauma Assessment

         All findings of a focused or detailed physical examination on the patient.  Place an "R" to indicate the

      patient's right side, an "L" to indicate his or her left side, or a "B" to indicate both sides in the appropriate

      boxes.  Open soft wounds include lacerations and abrasions, while closed soft wounds include bruising.  If

      the patient suffered no trauma, you can place an "X" or a slash across the entire section.

 ► Section 9:  Treatment

      All treatments rendered to the patient.  Remember to record the flow rate if you administer oxygen.

 ► Section 10:  Transportation & Refusal of Transportation

• SOR and Refused Transport:  Patient refused transportation to the hospital and signed the SOR (statement of refusal/signature of release) on the back of the patient report.

• Private Vehicle:  A family member or friend drove the patient to the hospital in a private vehicle.

• Ambulance:  An ambulance was called to the scene.  If you check this, you must complete the portion on the right side of the box, as well.

• Coroner's Case:  The patient died under circumstances warranting coroner inspection.

• DNR:  The patient died as a result of medical personnel withholding CPR and other lifesaving measures due to a valid DNR (do not resuscitate) order.

• No Patient:  A situation occurred at the event which an EMT wished to document using a patient report, but IU-EMS did not treat any patient.  For example, an event participant or bystander required assessment and treatment but refused to give consent.

• Disregarded:  A situation occurred at the event which an EMT wished to document using a patient report, but IU-EMS was disregarded from treating a patient.  For example, an ambulance crew reached a patient before IU-EMS did and disregarded IU-EMS personnel.

• 911 Called:  The time you call IUPD to request an ambulance.  Remember to use military time.  For example, "1630."  Remember to not call 911, but to call IUPD at 812-855-4111.  Store this number in your cell phone!

• Ambulance Arrival:  The time the ambulance arrived on scene.

• Ambulance Departure:  The time the ambulance departed the scene, with or without the patient.

• Transported:  The ambulance crew transported the patient to the hospital.

• Ambulance SOR:  The patient refused transportation to the hospital and signed an SOR with the ambulance crew.

• Additional Units on Scene:  Any other public safety personnel present at the scene.  If BHAS is present, record the ambulance's unit number.  For example, "206."

 ► Section 11:  Narrative

• Primary EMT's detailed explanation of the patient care situation.  Usually written chronologically, the narrative details how the situation began, progressed, and ended.  The primary EMT must include obtainment of patient consent and all patient assessment findings not indicated elsewhere on the  patient report, including pertinent negatives.  For example, "Patient denied head, neck, or back pain."  The primary EMT must also include all patient treatment, and must detail the termination or transfer of patient care.

 ► Section 12:  Primary EMT Information

• Primary EMT's signature, printed name, and certification number.  The signature indicates full medical and legal responsibility for the patient.

 ► Section 13:  Assisting EMT Information

• Assisting EMT's signature, printed name, and certification number.  If multiple EMTs assisted the primary EMT, the one who was most involved in patient care must complete this section.  The primary EMT cannot complete this section.  If no other EMT assisted the primary EMT, he or she must place an "X," a slash, or an "N/A" in this section.

 ► Section 14:  Patient's Printed Name

• The patient must print his or her own name on this line.

 ► Section 15:  Patient Initials

• The patient must print his or her own initials under the "Yes" column for each of the four items for the SOR to be valid.

 ► Section 16:  Patient Signature

• The patient must sign his or her own name on this line.  The signature indicates full release of IU-EMS from responsibility for any subsequent condition the patient experiences.

 ► Section 17:  Primary EMT Signature

• The primary EMT must sign his or her own name on this line.

 ► Section 18:  Witness Signature

• A witness must sign his or her own name on this line after the patient and the primary EMT have signed their own names on the corresponding lines.  The witness must actually watch the patient complete all three of the patient sections and watch the primary EMT sign his or her own name.  The witness should be an assisting EMT if possible, or else an assisting First Aider.  If neither an assisting EMT nor an assisting First Aider is available, then any bystander can serve as a witness.  If no witness is available, the primary EMT must place an "X," a slash, or an "N/A" on this line.

 ► Section 19:  Narration Continuation Page Number

• Ensure that each narration continuation page is numbered appropriately.  Place an "X" or an "N/A" on the "Run #" line.

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IU Dance Marathon 2006

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