Administration and Leadership, Documentation & Patient Care Reporting, Patient Care

Write It Right:Keeping your PCR clinical & factual

Issue 4 and Volume 33.

Rescue 5, respond to 555„Randolph. Man shot.Ó As the two paramedicsƒone white, the other blackƒrace through the night, one of them says to the other, ˙Well, another night in the Âhood.’Ó They both chuckle, remembering all the crazy calls for drunks, ODs and late night brawls that have occurred after closing time in this part of town. ˙Yep, just another night in the Âhood.’Ó

˙Rescue 5, Law enforcement on scene. One subject in custody on the playground.Ó

As they arrive, they see five cruisers with lights flashing. They’re directed to the playground, where they find a large white man being held face-down on the ground with his arms handcuffed behind his back. It’s confirmed he’s their patient.

The following is an actual narrative submitted with the run report. The obscenities that appeared in the actual narrative have been censored here.

On arrival, we found the subject face down on the ground with blood coming from his nose and mouth. I asked the man what had happened, and he said, ˙F*** You, Motherf***er! I wasn’t doin’ nuttin and dis white pig came and started bustin my ass!Ó I told the man to watch his language and he threatened me by saying, ˙F*** You and yo [N-word] partner!Ó He then began to spit blood in my face. The cops held him down while I placed a surgical mask over his face. He had not been shot. He did the shooting and was thrown to the ground by the cops and that’s how he got a bloody nose. We walked the subject to the ambulance and transported him to the hospital. I told him that spitting blood in my face was a crime and that I was going to file assault charges against him. He responded with ˙F*** You, I’ll kill you iffin I get da chance.Ó My partner witnessed these events.

Now that you’re appropriately shocked, let’s get the rest of the story. As it turns out, there was no shooting. The man’s ex-girlfriend called police and said he had a gun. When police arrived, an argument ensued. The neighborhood has a long record of violence and poor relations with law enforcement. The man was wrestled to the ground and hit his face on the concrete. He suffered a basilar skull fracture and filed a negligence suit against the„EMS agency and a civil rights lawsuit against the police department. Of course, the patient care report (PCR) was subpoenaed.„

How do you think the media would interpret this narrative? What does it say about the crew’s demeanor during the encounter? Does the provider appear to be a patient advocate, a potential litigate or even a witness for the prosecution?

How & Where to Write It
Caring for angry, violent and intoxicated patients is an accepted part of our job. There are many reasons for our patients to be upset. However, they’re often more angry at someone else than they are at us. Our arrival in conjunction with law enforcement and the fact that we wear a uniform places us on the same level of contempt the patient has for authority.

I’m often asked, ˙How do I document these types of encounters? I want to retain my right to press charges.Ó Or someone will say, ˙I want to help the cops nail that guy!Ó

My answer is two-fold. First, there’s the PCR. This must be an unbiased account of the patient’s care. It must be factual and contain nothing you wouldn’t be willing to swear before a judge was the ˙whole truth and nothing but the truth.Ó The sole purpose of the PCR is to document the medically pertinent events of the case. There’s no burden on you to complete it in a manner that will legally protect the patient, law enforcement or another individual. It should contain no more and no less than what we learned in school with SOAP, SAMPLE, OPQRST and all the other approaches to recording our care.

In the heat of the moment, it’s easy to vent your anger and frustration while writing the reportƒby using quotations, capital letters and what you consider ˙the way they talked.Ó But this is not the place for such narration and editorial. It exposes your bias and lowers the credibility of the report. Other reports completed by law enforcement will bear out the nature of the patient’s behavior. If you begin to point an accusing finger at your patient’s character, be prepared to have your own character scrutinized in response.

Second, every service should have a departmental incident report that can be completed after the call and kept in-house or provided to legal counsel for future use if needed. However, not being a part of the patient’s medical record doesn’t protect it from discovery in the event of a suit, but it does make its purpose clearly separate from that of the PCR.

In the incident report, you may write whatever you feel necessary to explain the extraordinary circumstances of the call. Remember that the truth of your statement can still be called into question, and you should stick to the facts.

Case, Take 2
Now, let’s try that narrative again:

Rescue 5 arrived to find a heavy-set white man being restrained by law-enforcement. He had blood running from his mouth and nose. When asked what happened, the patient responded with profanity and racial slurs towards me and my partner. The patient began to spit blood; therefore, for his safety, a spit mask was applied. The patient refused to answer any pertinent questions or cooperate with attempts at assessment. Despite this, a baseline set of vital signs was obtained.

The patient was breathing spontaneously. Neuro: Alert. Pupils: PERRL. No pain to neck palpitation and no apparent focal weakness. No other apparent signs of trauma. Prior to arrival, his hands were restrained behind his back with handcuffs. CMS to his hands was checked repeatedly. The patient was transported in the left lateral recumbent position with the head of the bed slightly elevated. Patient continued to resist efforts to assess him or obtain a history during transport but remained awake and alert with a patent airway and care was turned over to„County„General upon arrival.

How do you think the media would interpret„this narrative? It’s probably so boring to them that it wouldn’t even deserve mention. And as far as the media is concerned, that’s our goal.

This narrative makes it clear that the patient wasn’t cooperative and used profanity and racial slurs, but the writer retained the aloofness required of an„EMS professional when documenting a case. There’s no overwhelming sense of ˙IÓ or ˙meÓ in the narrative; instead, it’s a patient-centered report of actual events related to the prehospital care. It shows that appropriate care was rendered according to protocol, and no one can question the provider’s motives.

Will the patient still sue? Probably, but you’d appear to be the consummate patient advocate, which will serve you well in the end. All because you wrote it right.

Dr. Wesleyis the Minnesota State EMS Medical Director, as well as the medical director for the Chippewa Fire District, Ashland-Bayfield Counties EMS, and the Apostle Island National Lakeshore.