It started out as a routine call for an assault downtown on a Friday night. Dispatch tells you the assailants are gone and the scene is safe. You arrive with a first-response engine to find a woman in her 20s, supine on the sidewalk near the staircase of a motel. A man, who identifies himself as her boyfriend, says they were "jumped" by three men and robbed. The patient was pushed down the stairs in the struggle. She has a decreased level of consciousness and responds to voice by moaning.
As you assess, treat and package the patient, the boyfriend appears very upset and concerned about her condition. You load the patient and transport to the nearest trauma center. The boyfriend says he_ll follow in his car. As you move the patient to the hospital gurney, dispatch asks if you can handle a priority one call around the corner. You quickly give the trauma surgeon a report and head out. It_s going to be a busy night.
By the time you write the report on the first patient, you_re three charts behind. You quickly document that the patient was involved in a fight, and you found her at the bottom of the stairs. You document your exam findings and treatment. Your report is brief, but clear and to the point. You didn_t put down the boyfriend_s account of what happened, which is different from what he_ll later tell police officers. They review your run report a few days later, but it doesn_t raise any suspicions. The patient dies a few days later without regaining consciousness. No one ever finds out it was the boyfriend who pushed her down the stairs.
The Importance ofAccurate Reporting
"The biggest thing we see being missed by paramedics in their reports are statements of the key players on scene," explains Dan Greco, chief deputy district attorney for Washoe County, Nev. "The suspect may be on scene, and the paramedics may not even know it. A person who appears to be an innocent party may be the perpetrator. Whoever is there, if they say anything about what happened [or] claim a connection with the injured party, this important information should be documented. In a murder case, it can happen that the victim is still alive but dies shortly thereafter. Any words from the victim can be very important." When documenting statements made by people on scene, it_s important to quote them as closely as possible and put their remarks in quotation marks to show that these are, in fact, statements and not interpretations by the provider.
According to Greco, paramedics are often so busy, if they don_t write it down right away, it_s difficult later, even a day or two afterward, let alone several months later during a trial, to reconstruct what was said. And if reconstructed later, the defense attorney will grill you about your ability to remember. Murder trials will use pathologists and forensic experts, not the paramedics, to testify about the injuries and cause of death. "We need the medics to testify about the simple facts of what they found and what the patient and other people at the scene said," he says.
Greco describes a case where the EMS crew documented what was said on scene and how it helped convict a murderer. A 16-month-old infant died due to hypothermia in a bathtub. No marks were found on the body. No evidence of physical abuse was noted. When EMS got there, the babysitter told them that he had just put the baby in a warm bath and went into another room for a moment to stop two other children from fighting. When he returned, the victim had slipped under the water. He said he pulled her out, began CPR and called 9-1-1 right away. At the hospital, the baby_s core temperature was 79_. Detectives talked to the babysitter, and he changed his story from what he had told the EMS crew, who had documented what he said on their chart. "We could show he was lying and the jury convicted the man of murder," Greco says. "If they had not put that in their report, he might have gotten away with killing the child. You never know how things are going to change."
If you know or even suspect your patient is the victim of a crime, it_s important to document your care in great detail. Not only will the police and DA_s office be looking at it, but the defense attorney will be, too.
In Texas, in 2003, two men got into a fight with a third man and were charged with assault. Several months later, the victim died, and the charge was changed to murder. The defense attorney acknowledged his clients got into a fight with the victim, but he claimed the victim died because the paramedics treated him improperly and placed the endotracheal tube in his esophagus.
Because the defense may be looking for any piece of information to exonerate their client, blame can be easily shifted to others involved in the incident, which means you may be at risk for legal exposure. Because of this, your documentation requires a greater level of detail than usual.
"It_s also important to document how many IVs and/or injections were given or attempted and the location of each one," comments Cynthia Wyett, chief investigator for the Washoe County District Attorney_s office. "This is so all injection sites can be accounted for or if there is one that can_t be explained." This played a key role in a prominent murder case of a public official in Nevada. A large amount of succinylcholine was found in the patient_s body. The paramedics in the area don_t carry this drug. The patient_s husband, a critical care nurse, was convicted of her murder.
Another element of proper documentation is accurately describing how you found the patient and if you moved anything on or near the patient in order to render care.
"If you move anything at all on scene, it needs to be documented," stresses Greco. "It_s OK to move things. Your job is to save lives, and we understand that. You may have to alter or remove clothing or jewelry over a wound to treat the patient, but take note of how you changed the scene and document it."
Greco says his agency once wasted a lot of time on a case thinking a witness had moved some things around after the crime. The victim had fallen between a coffee table and the couch, and a seat cushion had fallen on top of the victim. The paramedic understandably moved the cushion to get to the victim, but they didn_t tell anyone they had moved it and didn_t document it. It occupied a lot of the investigating team_s time trying to recreate the sequence of events to explain how the cushion ended up where it was found by the detectives. "Any time a medic alters anything on the victim_s body or near the victim_s body, we need to know about it, and it should be documented and an officer informed."
In any case involving a major crime and EMS response, you can count on the run report being reviewed by law enforcement. "It may be for a small but very important point. In one case, medics and fire arrived ahead of police, and an apparent witness tried to point the finger at a certain individual. This person_s statements were documented in the run report," says Greco. "When this witness was interviewed by detectives several hours later, he told a very different story. Using the run report, we could show the person had changed their story dramatically and was lying, and he was ultimately proven to be the perpetrator," says Greco.
Documentation should be accurate, clear and concise. Neatness and spelling count. The more severe a possible sentence at stake for the defendant, the harder the defense attorney will try to discredit you. This means they could attempt to make you look foolish to the jury by criticizing your handwriting and spelling.
Fact vs. Truth
An important concept of documentation is recordingfacts, not the truth. A fact is objective; truth is a judgment or conclusion. For example, calling a wound "self-inflicted" is a judgment, unless you can back it up by documenting patient or witness statements. Another trap EMS personnel fall into is documenting a person as being "drunk" or "intoxicated." This is also a judgment or conclusion. Document only the facts and let the reader make a conclusion.
You might be tempted to document whether a wound was made by a knife or a bullet and if it_s an exit wound or entrance wound. We_re not trained or expected to differentiate between these. Wounds types are very difficult to distinguish. It can be hard, even for experienced detectives, to tell an exit wound from an entrance wound. The appearance of bullet wounds depends on many thingsƒthe angle the bullet entered and exited, what bodily structures it encountered, how much energy it had, etc. Describe only the wound_s size, shape and location. If there_s any soot or black powder visible around the wound, document that finding, because the substance may get cleaned off during treatment.
Calls involving possible child, domestic and elder abuse can be difficult to prove or disprove, but an accurate EMS report can be very important in such legal cases. This is where objectivity is crucial. A precise documentation of all injuries should be made, including location, size, shape and color, which may indicate wounds in various stages of healing. Document what other witnesses tell you about what happened, as well as what the patient says and their behavior and manner. Put down what you saw and heard, but don_t interpret what it means. If you include judgments, you can end up getting grilled for 30 minutes by a defense attorney about your training and expertise.
Reports on Trial
You may go your entire career without treating a murder victim. However, odds are you_ll end up testifying in some kind of criminal case (the most common being those involving driving under the influence). The likelihood increases if you_re on scene before law enforcement. Your documentation of any vehicle collision should include the patient_s position in the vehicle (e.g., driver_s seat, front or rear passenger seat). In addition, your documentation of such objective physical findings as slurred speech, odor of alcoholic beverages, patient_s response to how much they_ve had to drink (a legitimate medical question) and results of blood glucose measurements are important to the prosecution.
Probably everyone reading this is thinking,But what about HIPAA? HIPAA has a section that deals with law enforcement and what can be disclosed to police by EMS. The situations are divided into three categories: disclosures required by law, disclosures permitted by law and discretionary disclosures.
Disclosures required by law:Situations in which a state law or regulation requires mandatory reporting could include child abuse, elder abuse and/or domestic violence. The laws vary from state to state, so be sure you_re up to date on your state_s requirements and local protocols. In addition, you must disclose information when you_re presented with a subpoena, summons or warrant, or an official administrative request/
Disclosures permitted by law: Protected health information (PHI) may be released without the patient_s consent if law enforcement needs it to identify or locate a suspect, material witness, missing person or the victim of a crime. You may disclose PHI about a crime victim to law enforcement if the victim consents to the disclosure. If the patient is unable to consent, then the PHI can be released if there_s an immediate need, such as determining if a crime had occurred or the location of other victims.
Discretionary disclosures: You may disclose PHI if you believe your patient died as a result of a crime. You may disclose PHI to a coroner regardless of the cause of death. You may disclose information you believe constitutes evidence of a crime committed on your organization_s premisesƒthe station, headquarters, the parking lot, in the patient compartment, etc. You may provide PHI to law enforcement to notify them of the commission, nature and location of a crime; the location of a crime victim; or the identity, description or location of the perpetrator of a crime.
If you have any questions about releasing PHI to law enforcement, contact your organization_s HIPAA compliance officer.
Many in EMS feel we should have no role in law enforcementƒthat we_re not the police. They_re right; we_re not the police. Our overriding principle is to care for our patients, including those involved in crimes, the best way we know how and to be their advocates. One of the yardsticks we use to measure our performance is the golden rule: Did we treat our patient the way we would want to be treated? By documenting the facts of what was said and what we did, we can help others discover the truth about what happened to our patients who are victims of crimes. Would you want anything different for you or your family?JEMS
Barry D. Smith, EMT-P, has been a paramedic for more than 20 years and currently works for the Regional EMS Authority,Reno,Nev. He has also worked as a volunteer firefighter and as a member of search and rescue and civil air patrol rescue teams. Contact him firstname.lastname@example.org.