EMS Documentation: The Truth About Sticks & Stones

Posted by on Sep 5, 2012 in Articles & Columns

“Sticks & Stones may break your bones, but poor documentation can end your career & cost you everything!”

Patient Care Reports (PCRs)

With every PCR you write, imagine that it will someday be enlarged and projected onto a giant screen for the Judge, Jury, Opposing Counsel, and General Public to see… and pick apart. How is your penmanship? How is your spelling? How well are your thoughts organized? What do these things say about you? How do they affect patient care?

It is not uncommon for people to leave such grammatical considerations back in college or even high school. Sadly, conventional wisdom (for many providers) is that PCRs are a matter of function, not form; jot it down and move on – “If they can read the doctor’s handwriting, they can figure out mine.” For many providers, simply spilling information on the form is enough. They argue that spelling is less important than meaning; organization takes too much time; they abbreviate properly where they can and abbreviate creatively where they cannot, and so on.

That line of thinking could cost a career—or worse. To a layperson on a Jury panel, a PCR that may be fully completed and accurate may still seem unreliable or even incomplete if it is sloppy, rife with misspellings, or disorganized. That’s just the beginning.

In this age of instant access to information and news, with YouTube and Google Alerts, the general public has a better view of the world than ever before. We watched the response to the 911 attacks, we watched as EMS workers rushed to save lives in the Minnesota bridge collapse, we watched as police apprehended Rodney King, we watched while OJ, Robert Blake, and Phil Specter got away with murder and all the while we formed our own opinions of what happened based on the snippets from the news or from what was streaming on the internet. We watched, and we judged.

Likewise, from day to day, crew’s quarters and hospital lounges are abuzz with Monday morning quarterbacking based on what was said and what was written about one call or another – and that’s just for fun.

To opposing counsel in a legal action against you, it’s not fun, it’s business. They will use your documentation to try and call into question your competence as a provider. In essence, your skill, ability, and you will be judged by your documentation. Defendants have lost cases for much less.

Another, less common yet still existent favorite of opposing counsel is the documentation phenomena of “magic” vital signs. Magic vital signs are those acquired by EMS personnel who only need to look at a patient to know what they are – without the cumbersome assistance of a BP cuff, stethoscope, or watch. They generally look like this: 120/80, 80, 16. If you ever find yourself documenting magic vital signs, you have much bigger problems than the opposing counsel who will chew you up and spit you out; you are in the wrong line of work. My suggestion is this: Quit your job and do something else before you kill a patient or wind up in jail…or both.

For the rest of us, there are simple concepts and tips to keep in mind with every PCR you write:

— Print clearly in black ink (unless your agency requires blue)

— Make sure that your spelling is correct.

— If you are in doubt, look it up or change the word.

— Use only approved recognizable medical abbreviations, otherwise spell it out.

— Double check, if necessary, to assure the accuracy of the patient’s name, date of birth, and other identifying information.

— If you are not sure, document that you are not sure and why.

— Double check each check-box to make sure that everything is covered.

— If something is missing, that part of the assessment may have been overlooked

— Confirm or reassess before marking the box. (There’s nothing quite like marking that a glass eye is midrange and reactive to light – I have seen it done)

— Employ a consistent method for tracking time and document accordingly

— Arrival, departure, transport time, etc.

— Treatment times (defibrillator, intubation, medication administration, etc.)

— Note times for any significant change in the patient’s condition

— Where appropriate, note timing related to occurrences prior to your arrival

– When the pain started

– When the injury occurred

– Etc

— Make sure that your narrative includes facts & details, rather than opinions and generalities.

— A detailed narrative is a sign of a thorough assessment and vice-versa.

— Be sure to describe what you see and hear (and smell, if necessary) throughout the call.

— Include your personal pertinent observations (not opinions or assumptions) about the patient and about the circumstances surrounding the call

— Identify and attribute statements made by others, especially statements about what happened prior to your arrival.

“…wife states that’s that…”
“…Joe Smith, bystander, said…”
“…first responders report that…”
“…Shawn Tubbs, the nurse at the facility, told us…”
“…bartender said that…”
“…according to Officer Jones (LBPD), several witnesses said…”

— Wherever possible, identify any witnesses you quote.

— Be an artist, paint a picture!

— Organize your narrative such that the reader can derive a complete sequential picture of the call from inception to Emergency Room.

— Do not rely on check boxes to tell the story

Finally,

— If you release a patient at the scene, document clearly and precisely EVERYTHING you did and said along with the patient’s response to it

— If you release a patient at the scene, find at least two witnesses, if possible, to acknowledge your advice to the patient and sign the PCR

— Be sure to include printed contact information for each witness

— Unless absolutely necessary, do NOT use fellow EMS providers as witnesses.

— Family members are best

— Bystanders and law enforcement are decent alternatives

Good documentation takes time and, after the 20th call in as many hours, you may be exhausted. But every PCR must be a careful combination of form and function. That document could follow the patient for a very long time; from the ER to the OR, from the ICU to the rehab center. Every person who sees that report must know with 100% confidence and certainty what you saw, what the patient and witnesses said, what you did, and when you did it.

Billing Forms For many providers, particularly in the private or third service arena, Billing Forms are the bane of EMS existence. All too often they are submitted with a woeful lack of information and an abundance of blank spaces and boxes. “I don’t have time for that, I have calls to run. Besides, that’s what the billing department gets paid to do!” is the general and flippant rationale behind that very dangerous thought process.

Like PCRs, Billing Forms share time in the [legal] spotlight and they can make for an opposing counsel’s dream-come-true. Because they are part of the patient’s record, Billing Forms can be as critical to your cause as PCRs. They tend to include space for assessment and treatment information and —as they say— if you didn’t write it, you didn’t do it. Even on a billing form and even if it is written on the PCR.

Indeed Billing Forms can be laborious and time consuming and not as alluring to EMS folks as PCRs, but they can be just as important. An incomplete Billing Form (read: Medical Record) can look very, very ominous against you on a big screen in a court room. In the words of Ricky Ricardo, you will have some serious “…splainin’ to do…”

Finally, Billing Forms are not just about the money; instead they are an extension of your care for the individual.  Beyond protecting your own reputation or career, there is an ethical duty to prevent the kind of unnecessary discomfort – and potential devastation – that accompanies insurance claims confusion or threatened credit.

One Last Thing – It is important to note that litigation is ruthless business. When your skills are called into question and large sums of money are at stake, the opposing side will use every means possible to compel a judge or jury to find you liable in a civil suit or guilty in a criminal case.

In addition to whatever else may be used for or against you, your documentation will be projected onto a giant screen in the courtroom for the entire world to see. The lawyers on the other side will slowly and painstakingly pick it apart, piece by piece, and spin every syllable against you – if they can; if, by poor documentation, you let them.

On the other hand, if your patient care skills are solid and your documentation is clear, complete, and precise, the life you save may be your own.

Leave a Reply