How to Write a Paramedic's Report

When you write a paramedic's report you must do so with accuracy and detail. A paramedic's report communicates medical information about a person as well as describes what happened to cause or resulted from a person's medical situation. Your report helps hospital personnel deliver more effective treatment. The details you record may also be used for any future legal medical action.

Things You'll Need

• Report form
• Patient's name
• Medical history
• Medical treatment
• Patient outcome
• Refusal form

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Instructions

• 1

  Record the patient's name on the report form and describe what the person is complaining of, including all symptoms the person is experiencing. If the patient is unable to give the information, get as much as you can from family members or witnesses. Include what happened when the problem began, when the symptoms started, how long they have persisted, and what, if anything, has been done to try to help the person, such as change in position or body location, food or drink given, and medications administered.

• 2

  Gather information about medical conditions in the person's history, such as any illnesses, prior surgeries or similar symptoms to what is occurring now. Write those on the report form. List all of the medications that the person is on and which ones he took that day and when. Double check spellings of all medications and include correct dosage and strength.

• 3

  Describe in detail what you saw when you arrived. If this is an accident, write down the appearance of the patient and where he was located. If you arrive at a patient's home, workplace or public area, describe the state of the patient and the surrounding environment. Pay close attention to the way the patient is behaving and write that down as well.

• 4

  Take the patient's blood pressure and pulse, and record it. Perform a physical examination, and record your findings. Pay particular attention to any body system that appears to be injured or in distress. If required, administer medication and list time, type, dosage, and strength of every medication you give. Note the time and describe in detail any medical intervention and how the patient responded.

• 5

  Make a conclusion about the possible diagnosis. Write down "rule out," followed by conditions/injuries you've determined are not present. This will help the nurses and doctors in the hospital immediately focus on what condition they should suspect.

• 6

  Write the word "plan," and give a brief synopsis of the situation. The plan should organize your information so you can read from it to give a clear, concise report when you call the receiving hospital during patient transport.