EMS Documentation: The Truth About Sticks & Stones

While this variation of the idiom may be my own creation, you will probably recognize this next line as being one of the most tired clichés in the EMS field.

“If you didn’t write it on your patient care report, you didn’t do it.”

Even if the statement is cliché, you should also know that it is 100 percent true as far as a judge, jury and opposing counsel are concerned. This brings us to the important concept of the patient care report, the proper completion of which is a fundamental necessity in protecting yourself, your career and your department.

Patient Care Reports (PCRs)

When you write a PCR, pretend that it will someday be enlarged and projected onto a giant screen for a court of law and general public to scrutinize. These questions should pop into mind: How is your penmanship? How is your spelling? How well are your thoughts organized? What do these things say about you? And how do they affect patient care?

While these may seem like small issues, they require serious thought. It is not uncommon for people to leave such grammatical considerations back in college or even high school. Sadly, many providers regard PCRs as a matter of function, rather than form. Some hold the notion, “If they can read the doctor’s handwriting, then they can figure out mine.” Many providers argue that organizational writing takes too much time, so they abbreviate properly where they can and abbreviate creatively where they cannot.

This line of thinking could cost you your career — or worse. To a jury panel, a sound PCR 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, the general public has a better view of the world than ever before. We’ve watched EMS crews worldwide respond to various significant incidents over the past several years, and we judged their performance based on what we witnessed. Even your crew quarters and hospital lounges are abuzz with Monday morning quarterbacking based on what was said or written about a call — and that’s just for fun.

But to an opposing counsel in a legal action against you, it’s all business. They will try to use your documentation to call into question your competence as a provider. 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 in order to perform an assessment — 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, then please find another line of work 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 whenever you write a PCR:

• Print clearly in black ink (unless your agency requires blue).
• Make sure that your spelling is correct. When in doubt, look it up or change the word.
• Use only approved and recognizable medical abbreviations.
• Double-check the patient’s name, date of birth, and other identifying information to ensure accuracy. If you are unsure, document the reason(s).
• Double-check each checklist box to make sure that everything is covered. There’s nothing quite like noting that a glass eye is midrange and reactive to light. I have seen it done.
• Employ a consistent method for tracking time and document travel times, treatment times, and changes in condition.
• Be sure to describe what you see and hear (and smell, if necessary) throughout the call.
• Identify and attribute statements made by others, especially statements about what happened prior to your arrival.
• Be an artist and paint a picture! Organize a detailed sequential narrative of the call from inception to emergency room.

Proper documentation is especially critical if you release a patient at the scene. In order to protect yourself from the possibility of a lawsuit, you should clearly and precisely document EVERYTHING you did and said along with the patient’s response. Also, find at least two witnesses, if possible, to acknowledge your advice to the patient, get their contact information and ask them to sign the PCR. Unless absolutely necessary, do not use fellow EMS providers as witnesses.

Good documentation takes time and you may not want to put the energy into it after responding to that 20th call within so many hours. 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 complete confidence and certainty that you did in fact respond to the call exactly the way you recorded it.

Billing Forms

Along with PCRs, many providers — particularly in the private or third-party service arena — consider billing forms to be the bane of all EMS existence. Here is another popular saying among those in the EMS field:

This is a very dangerous thought process. These forms are all too often submitted with a woeful lack of information and an abundance of blank spaces and boxes. However, billing forms can be as critical to your legal precaution as PCRs because they are part of the patient’s record. 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 if the information is already written on the PCR.

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

It is important to note that litigation is a 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 (both the PCR and billing form) will be very visibly displayed for all to see. The lawyers on the other side will slowly and painstakingly pick apart every piece and spin every syllable against you. And if you find yourself producing poor documentation, then in the words of Ricky Ricardo, you will have some serious “splainin’ to do.”

On the other hand, if your patient care skills are solid and your documentation is clear, complete, and precise, then the life you end up saving may very well be your own.