30 | Documentation

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Last updated 5:02 PM on 7/29/26
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11 Terms

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prehospital care report

factual record of events that occur during an EMS call or other pt contact

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addendum

if an error is discovered after a chart is complete, submit an …

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libel

written false and malicious words intended to damage a person's character

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slander

spoken false and malicious words intended to damage a person's character

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against medical advice (AMA)

refusing medical care even though EMS clinicians inform pt that care is advisable

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capacity

EMS practitioners cannot make a legal determination of competence, but can legally determine …

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CRAM

mnemonic for documentation of pt refusals

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Communication ability

CRAM | C

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comprehension of Relevant information

CRAM | R

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Appreciation of the situation

CRAM | A

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ability to Manipulate information in a rational manner

CRAM | M