Documentation Reality Check

Posted by on Sep 4, 2012 in Articles & Columns

Document Realty CheckDocumenting What Didn’t Happen Can Be as Important as What Did

It was a great story back in 2007 when it first hit the news and for the EMS providers who responded, it was the call of a lifetime: Celestial Love Triangle! Former astronaut Lisa Nowak was accused of driving through the night from Houston and attacking Colleen Shipman at Orlando International Airport because both were vying for the affection of another former astronaut Bill Oefelein.

In the big picture, as a news story, it had everything: passion, romance, sex, weapons, stalking, insanity, NASA, and a cross-county race in a diaper. However, as 911 calls go, by itself it was not that exciting; not too challenging from a documentation standpoint…or was it?

On October 9, 2009, some two years after the incident, a Florida Judge ruled that he would not throw out the burglary with assault or battery charge against Nowak. At issue was whether Nowak actually attacked Shipman with pepper spray. The prosecution says she did, while the defense denies the allegation.

Both sides seemed to recognize that there are inconsistencies with stories Shipman told police, the EMS providers, and in subsequent depositions. Where did the court look for clarification? That’s right, the EMS run report. Despite telling the police otherwise, according to an EMT report uncovered by Nowak’s defense attorney, Shipman denied having any contact with pepper spray. The judge has ordered Shipman, the police officers and the EMS providers to be re-questioned because of the inconsistencies.

Needless to say, if it comes out that the EMS documentation is accurate, Shipman was never attacked by pepper spray, the dynamic of the entire case will change. The course of a felony criminal proceeding will be forever and permanently altered based on EMS documentation that had nothing to do with patient care.

If I have said it once, I have said it a million times: EVERYTHING you document matters. The law will creep up behind you when you least expect it and your run report will light up the big screen in court. Even though your patient care is not in issue (yet) each one of your words will be parsed and analyzed, every phrase interpreted; your neatness, spelling, and organization will be evaluated and you will be judged alongside your words.

When it is your turn, what will they find? What will it say about you?

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