Be Brief & Accurate on Patient Care Reports

What you document today may help or haunt you in the future


 
 

A.J. Heightman, MPA, EMT-P | From the October 2011 Issue | Saturday, October 1, 2011


At 8 a.m. on a recent Sunday morning, I heard a knock on my front door and saw a woman standing stoically on the porch. I thought it was one of those “Hi, we’re in your neighborhood providing free estimates on ...”calls.

But instead, she informed me I was being served with a subpoena to appear for a deposition in a high-profile case that I’ll write about after the trial concludes.

The feeling I got when I was served this legal order was similar to what you feel when you’re pulled over by a police officer and don’t know why. You know that both the prosecution and defense attorneys will be present when you are deposed, with each trying to get you to say things that are in their client’s favor and attempt to poke holes in your testimony in front of the jury.

I appeared at the designated time, and after raising my right hand and swearing to tell the “whole truth and nothing but the truth,” I spent two and a half hours being grilled by both attorneys.

Several of my responses were met with an objection by the opposing attorney as irrelevant or conjecture on my part. These responses were embedded in the deposition transcript that I would later have to sign and also remember when I’m called to the stand at the trial.

My reason for telling you the lessons I’ve learned is to help you prepare to give a deposition or appear as a witness in a tough case in the future, and, because this month’s JEMS article on child abuse points out your responsibility to report suspected abuse and carefully document your observations, conversations and clinical care.

You see, “my first lesson” in legal saber-rattling occurred almost 30 years ago and left such a big impression on me that I can recall it (similar to a nightmare) like it occurred yesterday.

I was a part of a two-person paramedic crew in Allentown, Pa., that was dispatched, along with police, to an “infant not breathing” call. On arrival, I found a 6-month-old infant who appeared lifeless in a crib in a back bedroom of an apartment.

The unkempt, unshaven guy in his underwear and dirty, sleeveless white T-shirt who called 9-1-1 was the live-in boyfriend of a young prostitute, who was at work at the time. The police documented those facts, not me; they had nothing to do with patient care.

I lifted the child out of the crib in the cramped bedroom, rushed into the living room, cleared off a cluttered coffee table with one swipe of my arm and placed the infant on what I felt would be a good platform for resuscitation.

I was the “airway paramedic” on that run, so I immediately began to position the child’s head to ventilate him.

My partner was fast and had already peeled open the tiny, sterile-packaged endotracheal tube; attached a small, straight blade; and was handing me the lit laryngoscope and tube as I positioned the infant’s head to bag-valve mask him. So instead of bagging the tiny patient, I chose to intubate him to establish a more secure airway.

What I saw around his tiny vocal cords when I advanced the laryngoscope blade was a circular mucus ring that I described in my trip report as “mucus in a Cheerio-like pattern around his vocal cords.” You can see where this is going.

At the deposition, as well as on the witness stand two months later, I was questioned about my depth of training, the number of pediatric codes I had handled in my career, the last time I was evaluated by an anesthesiologist on my intubation skills and, most importantly, who taught me how (and what they taught me) to document from my assessment, scene observations and care rendered. It was a tense, humbling and educational experience.

As a result of the poor choice of words I recorded in my report, the defense attorney tried to get me to say that perhaps it was a Cheerio I saw and that it could have resulted in the infant choking to death. But I quickly pointed out that what I saw and documented was “a Cheerio-like pattern,” with the center area open as though the infant took a breath and popped a bubble during inhalation or exhalation.

But my two real documentation victories that day that helped put the man behind bars for second-degree murder were: 1) that I palpated (and announced to police standing nearby) multiple depressions on the infant’s skull when I positioned his head for intubation and 2) that the man reported to me (in front of the police) that he was “sitting on the toilet in the bathroom” and saw the child gasping for air in the crib.

The autopsy confirmed multiple skull fractures inflicted on the child, and the police photographer showed the jury that there was no way a person seated on the toilet in that apartment could see a child “gasping for air” in the crib.

On all cases, not just pediatric cases, you should be brief and accurate with your documentation and complete every trip report as though it will be subpoenaed, because the reality is it very well might be. JEMS

This article originally appeared in October 2011 JEMS as “Be Brief & Accurate: What you document today can help or haunt you tomorrow.”




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Related Topics: Patient Care, Special Patients, September 11, from the editor, A.J. Heightman, 9/11, Jems From the Editor

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A.J. Heightman, MPA, EMT-P

JEMS Editor-in-Chief A.J. Heightman, MPA, EMT-P, has a background as an EMS director and EMS operations director. He specializes in MCI management.

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