As the head of the Quality Assurance Committee for your service, you review all patient care reports prior to passing them on to the medical director. On one trip sheet, you note the following narrative: Patient states that he cannot move his bowls and has had abdomenal pane for three weaks. Patient also states that he has had a fever and took too Tylenol tablets this morming, but then became naseated.
What advice would you give the paramedic regarding this report?
A . Have the EMT-B do all of the documenting.
B . Make up abbreviations for any words he is unsure of how to spell.
C . Only document what you know how to spell.
D . Get a dictionary and look up any questionable words when documenting.
Answer: D
Explanation:
Proper spelling is critical to prehospital documentation. Documentation containing spelling mistakes looks unprofessional and can cast doubt on the quality of care provided. Therefore, it is best to advise the paramedic to use a dictionary and look up any and all words that he is unsure of how to spell. Having the EMT-Basic document the advanced level care is inappropriate.
However, it would not be inappropriate to have the EMT read over the documentation to point out spelling errors. Making up abbreviations for words the paramedic is unsure of how to spell can create additional confusion and is not considered good practice. Just documenting the aspects of patient care for which the paramedic is comfortable with spelling creates incomplete documentation and is likewise inappropriate.