After a few months of working for a non-911 service I've noticed something. I feel like my reports are all very similar. It seems like I write a lot of pertinent negatives. Like for an abdomen I'm still doing a quick head to toe and putting in my report, so I'm going on about chest rise and fall etc before getting to my abd assessment. So my reports say a lot of the same things with minor variations. Am I putting too much useless info in my reports?
A habit or routine will save your bacon 10 times before it'll ever hurt you. (Unless you count a little extra work as hurting, but really, habits reduce your work, because you don't have to decide what to do each time; you just do it.)
With that said, eventually more targeted documentation is valuable, partly because it can mean adding things, not just leaving them out. When considering reporting a piece of information, think about it this way: could that information possibly be relevant? If you were telling somebody who had a reason to care about the patient (receiving staff, your boss, God), and they're going through the same process you did of thinking through the diagnostic and treatment pathway, what will they want to know? What could they care less about? Some things are important for painting a general picture, some are important for answering specific questions (ruling in OR out a particular pathology), and some are irrelevant.
Knowing what matters requires knowing a decent amount of medicine, of course, which is why it takes some time. "Aha" moments where you suddenly realize why a finding is often documented are common. So err on the side of caution.
Stuff you document purely to cover your butt is another matter entirely.
