EMS Operations, Documentation, and Professionalism
Operations and professionalism items test documentation, consent, confidentiality, handover, and ethical conduct.
Core rules
- Document objective findings, interventions, times, and response. Use a clear format such as SOAP or CHART; complete the patient care report before end of shift.
- Obtain informed consent for treatment and transport. For a refusal, assess capacity, explain risks, offer alternatives, and document the refusal and witness.
- Maintain confidentiality; share information only with those involved in care.
- Give a structured handover (e.g., SBAR) including chief complaint, vital signs, interventions, and response.
- Professional behavior includes respect, honesty, and working within scope of practice.
- Complete vehicle and equipment checks at the start of shift and report deficiencies; response times and dispatch information must be recorded accurately.
Worked example
A competent adult with mild ankle pain refuses transport. You explain the risks, offer advice, confirm he understands, and document his capacity, refusal, and signature. You do not transport against his will.
Traps
Incomplete documentation; accepting a refusal from a patient without capacity; breaching confidentiality; and giving a disorganized handover.