Updated April 14, 2015
Recently I had the distinct pleasure of teaching with my good friend and colleague W. Anne Maggiore. “Winnie” is from New Mexico and is among other titles, a paramedic, former fire chief and current attorney who is well known as one of the top EMS law experts in the country. We taught a full day workshop on medical-legal issues at one of the local EMS services. For a potentially dry subject I had rather low expectations for attendance; however, more than 140 personnel attended the program over a two day period!
We simply don’t teach enough about this area of our practice; in fact, many of us get very little information at all in our primary training. Consider that we practice medlegal concepts on every call we go on, even if we don’t transport a patient! Doesn’t it make sense that we have a clear understanding of our duties and obligations to not only our patients, but ourselves?
I presented information on documentation practices. Again, I thought it was going to be a challenge to present dry material in front of a group of very seasoned EMS professionals — boy was I wrong! Based on the volume of questions and comments, it was clear to me that people were concerned about their documentation abilities, and that they were motivated to do a good enough job that, if they were summoned to trial as a witness or defendant, would provide them a clear “memory” of an incident that may have occurred many months or years earlier.
Here are a few top tips for better patient care documentation:
1. Write it down.
We document so we can record, in near real time, the condition of the patient as we found him, the treatments we provided, and the patient’s response to those treatments. We also record for research purposes, quality improvement, and reimbursement. In another words, there are real-world reasons why documentation is important. Oh, and one more reason - ‘cause we have to! All states require documentation of health care, including interventions by first responders (paramedics on engine companies, did you hear that?)
2. Be consistent.
There are a variety of mnemonics for documentation — CHART, and SOAP are just two of them. There isn’t just one way to document. However, the “best” way is to use whatever technique consistently. Don’t change it just because you don’t transport a patient, or if it’s a BLS versus ALS patient. The more consistent you are, the less likely that you will forget to chart something.
3. Record your uh-ohs.
Don’t let unusual circumstances or events drop off your memory radar. You may have had an extended ETA. On scene time may have been much longer than normal. The patient was unruly, making it difficult to record your first set of vital signs. You may have experienced equipment failure. The patient may have declined transport. Record that information somewhere. It might not go on the patient care report, but most, if not all organizations have additional forms to record these unusual occurrences.
4. Document the unthinkables.
As Winnie calls them — these are the cases that you’re pretty certain will involve regulatory or law enforcement, such as abuse, neglect, rape, and violent crime. Take care to document what you saw, and heard during these incidents. Police and social case workers will be very appreciative of your efforts.
5. Write it down right away.
Most EMS systems have transitioned from paper to electronic documentation. While great for data recording, they can be a challenge to use when trying to document care. While you may not be happy with this type of “progress” it makes sense that you become fully aware of what it produces for documentation after you enter in the information. Remember that it can become quickly difficult to remember information after a call if you have to return to the station to document, rather than doing it right after the call. Jot down your times and other small bits of information to help jog your memory.
6. Double check your work.
Before you submit the paperwork, review it. Does your story make sense? After all, remember who is going to read your PCR — physicians, nurses, and lawyers whose intent is to find out if you did anything wrong. Nothing sends up a red flag more quickly than to have a written form that is contradictory with itself. Good documentation is good patient care.
See any I missed? Maybe you have a few more that you want to share with other readers? If so, submit in the comments below.
