EMS Insider, Expert Advice

Documentation

Documentation is the single most important step that has to be done during and after patient care, so why do so many EMS providers take it lightly? Sometimes it seems like we have more paperwork to fill out than the hospitals themselves, but why is it important?

All the legalities involved in patient care these days are horrendous. It is your job to see that every square inch of your EMS report is covered and that your narrative even covers more than just what the report checkboxes can provide. This goes hand-in-hand with the million dollar phrase, “If it’s not documented, it didn’t happen.”

Chances are you or one of your colleagues has been placed on the stand in a court of law due to failure to document some critical piece of information. This not only puts your reputation on the line, it also gives your department a black eye and maybe the wrong kind of publicity in the headlines of tomorrow’s newspaper or the nightly local news. How do you protect yourself and your department? Complete, thorough documentation.

Your report is a legal document and part of the patient’s medical record. Lawsuits are won and lost through documentation. Guilt or innocence can also be determined in criminal cases. When a summons appears, you need to be prepared. You don’t want to fumble through a report on the stand with only half the information.

Why are reports not thoroughly written? Some of the causes are just pure laziness, which usually relates back to that type of person who doesn’t want to be on the ambulance in the first place. Other reasons for lack of documentation relate to complacency, new EMS providers with lack of experience or simply not doublechecking your report before leaving a copy of it at the hospital. Some paramedics just don’t take it seriously enough to care about the quality of their reports.

I once saw a great risk management speaker who stated that if accidents are predictable they are preventable. It’s no different with an EMS report. Mistakes are predictable and they are preventable. Training on documentation and going over your department’s particular run sheets or entry of computer-generated reports should be considered a priority. Make it a habit to incorporate this type training on a regular basis throughout your department. Your quality assurance manager should also assist with documentation training. The QA division of your department should be the biggest advocate of complete and proper documentation.

Having a documentation program in place is proactive and should not be looked upon as punitive. Demonstrate to your personnel that this is purely constructive feedback and not something to be punished. Take the time to read your feedback materials and use them as a learning tool so that mistakes or lack of documentation doesn’t happen again. Learn something from it and don’t walk down the hallway of complacency.

Now with the non-punitive approach being said, QA can also be used to identify ongoing problems that never seem to get fixed with the next patient report. If constructive criticism doesn’t fix the problem, then a course of corrective action should take place on a formal level with whatever system your department has in place. Proper documentation should be taken seriously on an agency-wide level.

Beginning the Narrative

Perhaps the most critical piece of documentation is the narrative, so let’s break it down into several pieces of information that should be written into your narrative according to different scenarios. Following are several common elements that get left out of reports.

The narrative should always begin at the time of dispatch, list the incident you were dispatched to and describe what was found upon arrival of the scene:

“Dispatched for a person in seizures. Upon arrival found 35 y.o. female in bed in bedroom at place of residence lying supine (C/O) Chest pain.”

Beginning every report the same way builds consistency. The above example has covered what your detail was for and what you found when you got there, which also describes the position in which your patient was found and possibly helps show any type of distress your patient was exhibiting.

Another item commonly left out is information about auto accidents. A good description of the scene is critical, especially with the rising number of lawsuits involving auto accidents and insurance claims (whether legitimate or not).

“Upon arrival of scene found 2-vehicle mva, head-on type collision with heavy front end damage to both vehicles with confirmed entrapment. Vehicle found upright with interior not intact and spiderwebbing of windshield noted. Also found airbag deployment and no seatbelt used by patient.”

This statement helps describe the scene and paints a picture for the receiving hospital of how the patient sustained the injuries.

Patient Refusals

I cannot stress enough the importance of thorough documentation when you have a patient refusal. These incidents have a high probability of coming back to haunt you if information is left out.

“Patient was advised to be seen at medical facility and was advised of the possible consequences of not being seen. Patient refused treatment and transport and patient signed refusal.”

Including this information in the narratives serves as protection for you because it shows that you did ask the patient to go to the hospital, but they refused to go. It’s also important to note that they the patient was advised what could happen if their current condition goes untreated.

How many times are EMS providers called back to the scene for the same patient and find them even more sick than they were or, even worse, find them in cardiac arrest? Then what happens? The family is going to want to know why your EMS crew didn’t take the patient to the hospital the first time. If it goes to court, the report needs to clearly show that you recommended transporting the patient and advised them of what could happen if they refuse treatment.

Other information that I have commonly seen left out reports is a description of the patient, along with signs and symptoms displayed by the patient. Just because this report is a refusal and no transport is involved is no excuse not to write a complete narrative describing the scene, patient, what they had to say, medical history and any treatment given or offered to the patient while on scene. Do not leave your report at On scene, patient didn’t want to go. These kinds of statements leave your rear end hanging out in the wind with nothing to fall back on if you were on the stand testifying.

Assessments

Describe your patient fully from head to toe. Other than what was found wrong with the patient, include other signs and symptoms in your report not found with the patient. This will establish that you were also looking for other things wrong with the patient and shows that a full secondary exam was completed. Don’t forget to add any other information, such as comments made by the patient or observations made pertaining to actions by the patient that could possibly be out of the ordinary. In some scenarios, clothing descriptions may be appropriate to include. If the patient makes any comments, place the comments in “quotations” or writePatient states… This shows the patient making the statements, not the EMS crew.

Treatment

Document any and all treatments that were performed for this patient, even treatments that were attempted but unsuccessful.

Treatment entails medications given, procedures performed and reassurance provided to the patient. Yes, you should state in your report that the patient was reassured. That is a form of treatment and is also your bedside manner. Bedside manner is a form of customer service that can give harm your department’s reputation if not handled properly. This can also be assessed within your QA division through the use of customer service feedback cards mailed to the patient post care. This lets you know how your customers are being treated and how happy (or unhappy) they are with the service the department provides. Customer service goes a long way when a levy is introduced in your community for further funds. The customer will remember this when it comes to time to place their vote.

Transport

When documenting transport of a patient, things to consider writing should be:

“Patient taken to (name of medical facility) at patient request (or parents’ request). Patient transported without incident. Patient monitored throughout transport. No changes in patient condition noted during transport. Upon arrival of medical facility, met by ED staff, report given and patient care transferred to ED staff room 8 13:00 hrs.”

This statement shows where the patient was taken to, that treatment continued during transport and shows any changes in patient condition, which will further document any positive or negative effects of EMS treatment to the patient. This statement also shows that your patient arrived at the emergency department, patient care was transferred to that medical authority and even which room the patient went to and what time patient care was transferred to the hospital.

The time issue may not seem like a big deal, but there have been court cases that reference patients who claim abandonment by the EMS crew because it wasn’t documented that another medical authority took over patient care from the EMS crew and at what time. It’s also important to get a signature from the person taking over medical care. This clears EMS of any negligence or abandonment in case something goes wrong.

Another factor to consider documenting during the transport phase of your report are personal items that were transported and left with the patient, i.e., watches and other jewelry, dentures, canes, medications or any other substances that have to be transported with the patient to the hospital. These items are frequently misplaced at the hospital or accidentally thrown away, and it can be a costly emission if the report does not specifically document the items were in fact transported and left in care of the hospital with the patient. When your commanding officer looks up the run report and he can honestly tell that patient or family member that the EMS crew left every personal item at the hospital with the patient, the burden is lifted and no cost to the department for replacement of these items should be incurred.

Another note to remember with all EMS run reports is that if you happen to forget something that should have been included in the report, write an addendum and include the date, time, patient name, run number if your department uses them, and the information that you are adding and see that it stays with the original report.

Conclusion

There are many different ways of writing an EMS report. Practice each form of documentation and see which best fits you. Read other narratives and take a few minutes to study several colleagues’ writing style and develop your own. If your department has a policy on reporting form, then follow that policy, know it and live it.

Don’t take run reports lightly because someday it may very well come back to bite you, even years after the report was written. Each patient report that you write should be better than the last. Be accurate, be thorough, be complete and don’t leave things blank. If the checkboxes in your report don’t pertain to the call, don’t just leave it blank, draw a line through it because this shows you have acknowledged every piece of your report for that patient.

Your documentation should show that you have met the required standard of care, regardless of whether you’re a basic, advanced or medic. EMS documentation is a form of risk management. Practice, be thorough, become one with the report, utilize documentation training and remember: If mistakes are predictable, they’re preventable.

Les Allen is a firefighter/paramedic with the Loveland Symmes Fire Department in Loveland, Ohio.