Vague Vs. Specific
Instead of “patient was drunk,” document this.
Slurred speech, odor of alcohol, unsteady gait, admits ETOH use.
Name one thing that proves capacity.
AOx4 or able to repeat risks.
If it’s not charted, it didn’t happen. Myth or fact?
Fact
Why document airbag deployment?
Mechanism of injury.
Complete: “Patient denies _____.”
Chest pain, SOB, dizziness, LOC.
Instead of “patient was fine,” give two objective findings.
AOx4, GCS 15, normal vital signs.
What must be documented in chest pain refusal?
Risks including MI/death explained.
Why are negative findings important?
They show assessment for serious conditions.
Why document empty pill bottles?
Supports possible overdose.
Complete: “No signs of _____.”
Trauma to head, neck tenderness, neuro deficits.
Rewrite “minor car accident” defensibly.
Low-speed MVC, restrained driver, no airbag deployment, no intrusion.
True/False: Signature alone protects you.
False
How do you document suspected intoxication?
Objective findings only.
Name one environmental fall hazard to document.
Wet floor, loose rug, poor lighting.
Complete: “Decision-making capacity assessed and _____.”
Intact.
Instead of “patient stable,” document this.
BP, HR, RR, SpO₂ listed with skin signs and speech status.
Name two risks for fall on blood thinners.
Name two risks for fall on blood thinners.
What do you document if patient refuses vitals?
Vitals Assessment offered, patient declined, risks explained.
Why document bystander statements?
Supports timeline and condition on arrival.
Complete: “Advised to call 911 for _____.”
Worsening symptoms.
Rewrite: “Pt fell. No injuries.”
Mechanical fall, denies LOC, denies head/neck pain, no deformities, ambulatory.
Risks, benefits, and alternatives explained and _____.
Patient verbalized understanding.
Name one dangerous vague word.
Fine / Stable / Okay / Normal.
What scene documentation helps protect you in domestic calls?
Scene safety, demeanor, injuries observed.
What phrase protects you best during refusal?
Patient verbalized understanding of risks.