Two days after a call, you realize that you forgot to document that you checked a patient's blood glucose prior to him refusing transport and signing the refusal form. At that time, you did contact medical direction and provide this information to the doctor, prior to him authorizing the patient to refuse. What is now your best course of action?

Emergency Medical Services (EMS) documentation is important for patient care and legal matters. Documentation can include the patient's demographics, vital signs, assessment, and interventions performed. The documentation serves as a data repository that can be used to create bills, facilitate communication, and guide quality initiatives.