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...


      2. Patient Transport Priority

      3. Transport Intended Destination

  F. En Route to Hospital

       1. Reassessments and Findings

       2. Vital Signs

       3. Additional Treatment Provided

       4. Any Consultation Information

  G. At the Hospital

       1. Destination of Patient (i.e. –Room Number)

       2. To Whom was Care Transferred

       3. To whom was the Report of Patient Care Given

 

V. Refusal Documentation (1-2-5)

  A. Legally Important

  B. Pertinent Information to Include

      1. Patient Identification Information

      2. Call Type

      3. Scene Description

      4. Subjective Information

      5. Objective Information

            a. Assess Patient

            b. Note Suspected Injuries

  C. Inform Patient

      1. Advise Patient of Risks

      2. Allow for Informed Refusal

      3. Document all Information Given by Provider

  D. A3E3P3 (Acronym)

      1. Assess – For Injuries

      2. Advise – Of Options

      3. Alleviate – Problems/Fears

      4. Explicit – Be Direct/Honest

      5. Exploit – All Avenues

      6. Explain – Ramifications

      7. Persuade – To be Transported

      8. Protocol – Follow Protocol

      9. Protect – Yourself, Crew and Patient

 

VI. Abbreviations, Acronyms and Symbols (1-2-6)

  A. Abbreviations

      1. Medically Accepted

      2. Shorthand

  B. Acronyms

      1. SAMPLE

            a. Signs/Symptoms

            b. Allergies

            c. Medications

            d. Past Medical History

            e. Last Oral Intake

            f. Events Leading to Injury or Illness

      2. OPQRST

            a. Onset

            b. Provocations

            c. Quality

            d. Region/Radiation

             e. Severity

             f. Time

      3. DCAPBTLS

            a. Deformities

            b. Contusions

            c. Abrasions

            d. Punctures

            e. Burns

            f. Tenderness

            g. Lacerations

            h. Swelling

      4. TTFN

            a. To Whom Care was Transferred

            b. Time

            c. Fluid Infusion

            d. Necessary Status Update

  C. Symbols

      1. Not many in EMS

      2. Listed in Handout

      3. Physical Therapy Symbols

             a. Right

             b. Left

             c. Increase

            d. Decrease

      4. Other Symbols

             a. At

             b. Degree

             c. Equal to

             d. Times

Summary:

Session 1

Lesson 1:2 Written Narrative Completion

Student Performance Objective (SPO):

Given 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.

Review/Main Points:

V. Written Narrative Completion

   • Effective Narrative

   • CHART format

   • SOAP(IER) format

   • Chronological format

   • Refusal Documentation

   • Abbreviations, Acronyms and Symbols

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.

Handout 1

Handout 2

Handout 3

Handout 4

Handout 5