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The Written Word: Using documentation to make fact-based decisions

My wife swears men should never leave for the grocery store without a list of what needs to be picked up. Before I leave on a grocery run, she_ll tell me what we need, I'll nod, and she_ll say, "Why don't you write it down?" And I_ll say, "Because I can remember everything so there's no need to write it down."

Here's my trick: I remember the total number of items to help ensure I get everything. If she says to get pickles, milk, chips and bread, then I put to memory that I need to get a total of four items.„

Naturally, when I get to the store, I remember only three out of the four. To make sure I don_t hear, "I told you so," when I get home one item short, I'll find myself walking up and down the aisles of the supermarket, trying to remember what's missing. Of course, I usually can't remember that one last item ... but I sure do pick up a lot of other goodies.„

What does this have to do with being an„EMS manager? Plenty. No matter how sharp our memories are, it's not just a matter of being able to recall an event or interaction. It's a matter of facts. We've always been taught that when it comes to patient-care reports, if it isn't written down, it wasn't done. The same is true with managerial documentation. If you don't write it down, it can't be proven later.

I've found there's a whole range of how„EMS managers record departmental activities. Some have no documentation on anything. Personnel files are empty. Training records are bare, and budgets are simply a copy of last year's data with the date changed.„

Others keep meticulous records on everything. They understand the legal importance of documentation, sometimes to the point of detriment. For example, one manager I know lives in such a paranoid world that he puts no opinions in writing, and if you e-mail him, he'll merely respond with "OK" or "Call me."„

How & how much

One of the best forms of documentation is e-mail. Besides documenting what you wrote, it can time and date stamp when it was sent and when the receiving party opened it. After a serious meeting with an employee, take a few minutes to send a follow-up e-mail to them to document what was discussed or makes notes for their personnel record.„

You should maintain written documentation on almost every managerial aspect of your job. It's not only about protecting yourself later if an issue comes up, but keeping records allows you to refer back to them to help guide future decisions.„

For example, if you have staff meetings, minutes should be taken, approved and disseminated. Minutes should include agenda points, as well as any "action items" that will need to be addressed before the next meeting and who's assigned to handle them. So if one member of your staff is assigned to complete a report before the next meeting, it should be marked as an "action item" and be placed on the next meeting's agenda for discussion.

What about when you attend meetings outside of your department, such as a local committee meeting? Should you take your own "minutes"? I attend a lot of meetings, and when I see people writing down notes on a legal pad, I wonder what they do with those notes. Are they making themselves look busy, just to later rip off the sheet and throw it in the trash? Or do they file them for the next meeting? I know both kinds of managers, but I'd say that if you're taking the time to attend the meeting, you should take the time to briefly record what you learned there.

The biggest problemƒwhat to do with it all? If it's e-mail, most software allows you to create "archive" folders. But paperwork is more of a challenge. If you're lucky, you have an assistant who keeps your paperwork in order. If not, it can be tough to lead your organization while doing task work. If you have no choice but to wear many hatsƒincluding manager, secretary and janitorƒdo what makes the most sense with the time you can afford to give each task. Just don't neglect the task altogether.

If you're ready to take on new technology, try to get your hands on a flatbed scanner. You can create PDFs or JPG files of old documents; save those digital files to a CD, DVD or external hard drive; then shred or recycle the original paperwork. You might also consider taking old documents to a copy shop and having them do the scanning for you.„

How long should you keep records? Good question! But there's a blanket answer. I still have important records from when I left the St. Louis Fire Department almost seven years ago. They're stored away in case I ever need them, because I learned early on that whenever I shredded old records or cleared out a file, I always needed it about a week later. So now I keep records I think are irreplaceable.

Summary

Documentation isn't only about keeping scrupulous patient-care records; it's about keeping detailed administrative records as well. Our departments rely on us to be the "memory keepers" of the organization, and with effective documentation methods, we can better remember where we've been and where we're headed. Now, if I can just learn to document my wife's shopping list!

Gary Ludwig, MS, EMT-P, is a deputy fire chief with the„Memphis (Tenn.) Fire Department. He has a total of 30 years of fire and rescue experience. He is chair of the EMS Section for the International Association of Fire Chiefs and can be reached at„www.garyludwig.com.

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