Title: Explain the components and legal considerations of EMS documentation.
Course: Emergency Medical Responder (14055-IV) > Section: Exploring Medical Responder Fundamentals

Explanation should include

- the principles of medical documentation and report writing
- the information included on a written or electronic report, including standard methods of recording patient information
- cybersecurity and privacy (e.g., Health Insurance Portability and Accountability Act of 1996 [HIPAA]) considerations.

Process/Skill Questions:

- How does an EMR use documentation to paint a picture for the patient-care continuum?
- What information should be included in the narrative section of patient documentation?
- What are the legal considerations of a patient-care report that is used as a court document?