The expectation now a day is that you know more and can do more as a paramedic. Along with those expectations comes the responsibility of better documentation. This is a craft you perfect over time. Here are some tips to help:
• Write more rather than less
• Write in detail
• Don’t be redundant
• Check your spelling (especially with an electronic system)
Remember that the information you write is sometimes the only history that is available (see TOTW HISTORY IS IMPORTANT). Document as if you were the one having to gather the information from the ACR in order to make the proper care decision for the patient.