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TL;DR

EMS Documentation: Patient care reports for legal and clinical continuity.

By Valenke Exam Prep Team·Last updated 2026-06-02

EMS Documentation

NREMT EMTNREMT PARAMEDIC

Definition

Patient care reports for legal and clinical continuity.

Calculation Methods

Dosage calculations related to ems documentation in EMS:

Pediatric dosing: always calculate by weight (mg/kg). Use Broselow tape if weight is unknown.

Related Procedures

Procedures related to ems documentation in the EMS setting:

  1. AHA ACLS cardiac arrest algorithm: CPR then rhythm check then shock if VF/pVT then epinephrine q3-5min then amiodarone
  2. Sepsis recognition: qSOFA of 2 or more (altered mentation, RR 22+, SBP 100 or less) then IV fluids 20 mL/kg then early antibiotics if ALS
  3. RSI sequence: preoxygenation then sedation (etomidate 0.3mg/kg or ketamine 2mg/kg) then paralytic (succinylcholine 1.5mg/kg or rocuronium 1mg/kg) then intubation then confirm placement with waveform capnography

Assessment Techniques

Assessment techniques for ems documentation:

SAMPLE
Components: Signs/symptoms, Allergies, Medications, Past history, Last intake, Events. Scoring: Mnemonic for patient history gathering
OPQRST
Components: Onset, Provocation, Quality, Radiation, Severity, Time. Scoring: Pain assessment mnemonic
Cincinnati Stroke Scale
Components: Facial droop, Arm drift, Speech abnormality. Scoring: Any 1 positive = 72% probability of stroke

Practical Example

Field Scenario: An elderly woman found on the floor after a fall. Alert but confused, hip pain with external rotation and shortening of right leg. Suspect hip fracture: splint in position found, monitor for shock.

This scenario tests your ability to apply knowledge of ems documentation under time pressure with incomplete information, exactly the type of decision-making the certification exam assesses.

Why It Matters

PCR documentation standards tested on EMT exam.

Related Terms

Patient Assessment SequenceSBAR Communication

Practice This Topic

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Frequently Asked Questions

What vital signs should be monitored when assessing ems documentation?▼
For ems documentation: GCS: 15 is normal, under 8 = severe TBI. ETCO2: 35-45 mmHg. heart rate: 60-100 bpm. Reassess every 5 minutes for unstable patients.
What assessment tools help evaluate ems documentation?▼
For ems documentation: SAMPLE: evaluates Signs/symptoms, Allergies, Medications, Past history, Last intake, Events; scoring is Mnemonic for patient history gathering. Cincinnati Stroke Scale: evaluates Facial droop, Arm drift, Speech abnormality; scoring is Any 1 positive = 72% probability of stroke.
What protocol applies to ems documentation in prehospital care?▼
For ems documentation: Trauma assessment: scene safety then MOI then primary survey (XABCDE) then rapid transport then secondary survey en route