Effective MAIS Reporting and Documentation

Effective MAIS Reporting and Documentation by: Carol L. Mitlacher, NREMT-P JoAnn M. Yost, BS NREMT-P United Steam Fire Engine Company Number 3     I. Effective MAIS Reporting and Documentation...


      3. Conditions

      4. ECG

      5. Circulation

  H. Cardiac Arrest Related

      1. Cardiac Arrest Witnessed

      2. CPR Started By

      3. AED Started By

      4. Return of Spontaneous Circulation at ED

  I. Airway, Procedures, Other Care Rendered

      1. Airway/Ventilation

      2. Procedures

      3. Other Care Rendered

  J. Medications

  K. Hospital Codes

  L. Transportation/Communication/Special Purpose

      1. Transported By

      2. Reason Hospital Chosen

      3. Radio

      4. Special Purpose

      5. Variable

      6. Provider Exposure

 

III. Refusal Forms (1-1-3)

  A. Refusal for IV Therapy

  B. Refusal of Services and Transportation

  C. Refusal of Services Not Transportation

      1. Procedure Addition – Combitube Dot Added

      2. Condition Change - Exposure to Environmental

 

IV. Upcoming Changes to MAIS Form (1-1-4)

  A. Web Based Data Entry System (Pilot)

  B. Current MAIS Document Changes

Summary:

Session 1

Lesson 1:1 MAIS Form Completion

Student Performance Objective (SPO):

Given information related to MAIS form components, the student will be able to complete an entire MAIS form according to the MAIS User’s Manual guidelines.

Review/Main Points:

II. MAIS Form Completion

   • General Rules

   • Components of MAIS Form

   • Refusal Forms

   • Upcoming Changes to MAIS Form

Evaluation:

Oral Review: Under each review point, recall and list three features from the discussion. Make a note of these points or highlight points in your notes as you may use them for exam review.

Other Evaluation: Use course quizzes, if any, or create and use lesson quizzes and other learning reinforcements. Quizzes are diagnostic and may be given as in-class group assignments to generate discussion or as home assignments and used as review prior to starting the next session.

III. Effective MAIS Reporting and Documentation

Instructor Guide

Session 1

Lesson 1:2

Title of Topic: Written Narrative Completion

Time: .75 hours

Teaching/Learning Level: Cognitive

Learning/Teaching Aids:

   • Lesson 1:2 Transparencies

   • Lesson 1:2 Handout

   • Overhead

   • Screen

   • White Board

   • Transparency Markers

   • Dry Erase Markers

Behaviors to Foster: Active participation and discussion to enable the students to effectively formulate written narratives and utilize abbreviations.

Task: Completing Reports

Given: Information and Knowledge about Narrative Formats and Abbreviations

Standard: Medically Accepted Abbreviations and Narrative Formats

Prerequisite Knowledge: Basic writing skills

Successful completion of EMT-B Module III Exam

Prerequisite Skills: Enhancement of Narrative Report Writing Skills

Resources/References: Report Writing Formats (as needed)

Attention: (Call to Order)

Motivation: (State Need to Know)

Student Performance Objective (SPO): Given the information and knowledge about narrative formats and abbreviations, the student will be able to formulate effective written narratives utilizing medically accepted abbreviations in accordance with medically accepted narrative formats.

Enabling Objectives (EO):

EO 1-2-1 Discuss effective narratives and some important items to include when documenting.

EO 1-2-2 List and discuss the components of the CHART format.

EO 1-2-3 List and discuss the components of the SOAP(IER) format.

EO 1-2-4 List and discuss the components of the Chronological format.

EO 1-2-5 Discuss effective documentation of patient refusals.

EO 1-2-6 Review common medical abbreviations and symbols.

Overview/Main Points:

 

IV. Written Narrative Completion

   • Effective Narrative

   • CHART format

   • SOAP(IER) format

   • Chronological format

   • Refusal Documentation

   • Abbreviations, Acronyms and Symbols

Opener: Call to order; start with a motivator (need to know) related to objectives and the lesson; state objectives and main points.

Teaching Points

I. Effective Narrative (1-2-1)

  A. Tells a story

      1. Accurate

      2. Concise