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Emerg Med Serv. 2002 Oct;31(10):89-90, 93-4.

Documentation: why is it so important?

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Persons who activate an EMS system expect a timely response from people who will be able to help them. When they don't get the service they are expecting, they may look for legal recourse. Hospital staff and healthcare providers expect prehospital care providers to follow protocols and standing orders in providing interventions to help stabilize conditions found during patient assessments. The results of these interventions must be conveyed via both oral and written documentation. Documentation of patient care, equipment maintenance, inventory control and training can help protect the assets of an EMS organization. It can help prove (in a court of law, if necessary) that the organization acted in a prudent manner. Documentation becomes the history of the organization. Does your history show that you are a professional organization?

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