As the head of the Quality Assurance Committee for your service, you review all patient care reports prior to passing them on to the medical director. On one trip sheet, you note the following narrative: Patient states that he cannot move his bowls and has had abdominal pain for three weeks .Patient also states that he has had a fever and took two Tylenol tablets this morning, but then became nauseated . What advice would you give the paramedic regarding this report?

Proper spelling is critical to prehospital documentation. Documentation containing spelling mistakes looks unprofessional and can cast doubt on the quality of care provided. Therefore, it is best to advise the paramedic to use a dictionary and look up any and all words that he is unsure of how to spell. Having the EMT-Basic document the advanced level care is inappropriate. However, it would not be inappropriate to have the EMT read over the documentation to point out spelling errors. Making up abbreviations for words the paramedic is unsure of how to spell can create additional confusion and is not considered good practice. Just documenting the aspects of patient care for which the paramedic is comfortable with spelling creates incomplete documentation and is likewise inappropriate.