Memo - Patient Reports Being Given to Hospitals
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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 . . .