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. Legible

      4. Complete

  B. Important Items to Include when Documenting

      1. Document Everything

      2. Use Additional Narratives

            a. Priority 1 and 2

            b. Refusals

      3. Apparatus and Crews on Call

      4. Events Leading to Incident

      5. Treatment of Patient

      6. Medic Information

             a. Name

             b. Rank

             c. Medic Unit Number

             d. MAIS Number of Medic Report

      7. Hospital Turnover Information

 

II. CHART format (1-2-2)

  A. C – Chief Complaint

  B. H – History

      1. Medical History

      2. Possibly Family History, If Needed

  C. A – Assessment

      1. Subjective - What was given?

      2. Objective - What information was found?

            a. Visual

            b. Audible

                  1) Patient’s Answers to Questions

                  2) Auscultation

            c. Olfactory

            d. Touch/Palpation

            e. Vital Signs –Include Time

      3. Overall Patient Status – Include Patient Priority

  D. Rx – Treatment/Therapy per Protocol

      1. Treatment Given to Patient – Include Time

      2. Patient’s Status

            a. Vital Signs – Include Time

            b. Changes in Patient Condition

  E. T – Transport and Transfer

      1. Transport

            a. Transport Destination

            b. Transport Time

      2. Transfer

            a. Whom was care transferred to?

            b. Time

 

III. SOAP(IER) Format (1-2-3)

      1. S – Subjective

            a. Chief Complaint

            b. Symptoms

            c. Self-Treatment

            d. Pertinent Medical History

      2. O - Objective

            a. Provider Observations

                    1) MVC – MOI

                    2) Scene Observations

                    3) Signs

            b. Vital Signs

            c. Findings from Assessments

      3. A – Assessment or Analysis of Assessment

           a. Provider Impression of Patient Condition

           b. Diagnosis not Expected

      4. P – Plan or Protocol

           a. Describe Every Aspect of Patient Treatment

           b. Keep in Chronological Order

      5. I – Implementation of Protocol

           a. Can be Merged with (P)

           b. Note Times of Implementation of Treatment

      6. E – Evaluation of Treatment

           a. Can be Merged with (P)

           b. Changes in Patient Status due to Treatment

           c. Reassessed Vital Signs

      7. R – Report Finale

           a. Can be Merged with (P)

           b. Transport Information

           c. Hospital Transfer Information

 

IV. Chronological Format (1-2-4)

  A. Dispatch

       1. Call Type

       2. Any Pertinent Information About the Response

  B. En Route to Scene

  C. On Scene

        1. Crew/Provider Observations

               a. Scene Observations

               b. Signs

               c. Subjective Information

                     1) Chief Complaint and Events Leading to Incident

                      2) Symptoms

                      3) Medical History

              d. Assessments and Findings

                      1) Vital Signs

                       2) Injury/Illness

  D. Treatment

      1. Chronological Order

      2. Time of Treatment Component

  E. Transport

      1. Patient Transport to Ambulance