Treatment Documentation · 10 min · EMT

Interventions & Response

Document what you did, when, dose/route when applicable, indication, and response. "Per protocol" alone is not enough—name the treatment.

Reassess after interventions; show the clinical arc.

Good snippet

09:20 Nitroglycerin 0.4 mg SL for suspected ACS; BP 142/88 → 128/80; pain 8/10 → 5/10 at 09:25.

Weak snippet

Meds given per protocol. Continued to monitor.

3-question check

0/3 answered

1. After medication, document:

ANothingBTime, dose/route, response/vitals trendCOnly "given"DOnly protocol number

2. "Per protocol" alone is:

ASufficient foreverBIncomplete without naming the interventionCA vitalDA destination

3. "Continue to monitor" should become:

ADeleted and ignoredBWhat you monitored + findingsCOnly radio codeDBilling text

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Lessons · Drills · HandoffNote

NarrativeCoach is a training aid only — not a medical device, not legal/billing advice, not an ePCR, and not CE/CAPCE. Never enter real PHI. Fictional scenarios only.