A guide for paramedics writing clinical records, by following this order of documentation and using the abbreviations below like PC, HPC and OE, will give you the framework for accurate and good documentation. Providing clear and accurate findings will help with the ongoing care by all health care providers.
PC - PRESENTING COMPLAINT
What is the primary symptom or injury?
HPC - HISTORY OF PRESENTING COMPLAINT
A brief history of events
OE - ON EXAMINATION
Include any current signs or symptoms.
Start with AVPU and GCS, document each body System separately under the OE heading as below.
- RS: Respiratory System
Respiratory rate, SPO2 level, chest sounds etc.
- CVS: Cardiovascular System
Pulses, BP, ECG, capillary refill etc.
- CNS: Central Nervous System
Pupillary response, pyrexia, paresis etc.
- ABDO: Abdomen
- LMS: Locomotor System
Any complaints or findings of skeletal or muscular origin - soft tissue injury.
- IMP: Impression
- Rx: TREATMENT
Include any medication prescribed by clinician or any intervention performed.
- PLAN: Plan of action
Note whether conveyed or discharged from ambulance care, or passed to other HC provider.
Document any advice given as appropriate.
Disclaimer: The information in this document has been taken from various sources and includes knowledge from registered paramedics, it does not replace formal training. The skills mentioned in this article may be taught and assessed differently as they are described here and should not be used in practice unless correct methods have been taught, assessed and the clinician or student is working within their scope of practice. The details in this article could be subject to change at any time without prior notice. Any feedback is always welcome Contact Us