How to avoid documentation disasters

“If you didn’t write it, you didn’t do it.” That may be the oldest and most tired cliché in all of EMS and it is not exactly true.

Likewise, “paint a picture & tell a story,” is another biggie in documentation classes. I happen to agree with that one; unfortunately, many providers are painting the wrong picture and telling the wrong story because they are not thinking about their audience. They are not considering who will be reading their report and why. Not to worry. I can fix it.

Contrary to popular belief, patient care reports are not created for the singular purpose of feeding the voracious appetites of greedy lawyers. However, at feeding time, lousy documentation — and your career — make for a nice meal and there are plenty of sharks eager to take a big bite out of your assets.

Know your audience

Like every call, every report is unique. There is a specific series of events (or non-events) that must somehow be recorded in a way that both shows and tells the reader what happened, and clearly describes your reaction to it. At the same time, for better or worse, the reader will gather some insight about your appreciation of the circumstances that brought you to the scene, your assessment of everything, your understanding of associated protocols, and your application of technique. That is a boatload of information for one narrative and how you communicate it will depend on who will be reading it, and why.

For example, the narrative for a fatal gunshot wound to the head that is left on scene for the medical examiner will look entirely different than that of a gunshot to the head that is transported and later dies. While the outcome is the same, the audience is different and thus the documentation is different.

Patient transports

First and foremost, for patients who are transported, patient care reports are generated so future caregivers can know what happened before the patient came to them. The information is used to diagnose or rule out medical conditions; to identify medications taken and known drug allergies so as to prevent lethal combinations or anaphylactic nightmares; to guide advanced clinical assessments and treatment modalities, and the list goes on. If your prehospital documentation is inaccurate or incomplete, the easily avoidable can become an irreversible tragedy in the blink of an eye.

The BIG Five

1. Write for doctors, nurses and allied professionals
2. Organize as if the patient will become unconscious and unable to provide any information
3. Assume that the person reading your report knows nothing about anything that happened before the patient arrived in the ED
4. Make sure the reader knows WHEN you did what you did
5. Presume nothing and leave nothing [relevant] to the imagination

Death in the field

Then there is the issue of death in the field. Most systems have protocols that allow providers to withhold treatment and transport for the obviously dead. When called upon to document death in the field, you are not writing for the sake of future care, you are writing for medical examiners, homicide investigators, and possibly even criminal prosecutors (and criminal defense attorneys). While dead men tell no tales, your death-in-the-field documentation will speak volumes about what did or didn’t happen; why that poor unfortunate is no longer an active participant in the game of life and whether you could have or should have done something about it.

The BIG Five

1. Write for medical examiners, homicide detectives and criminal justice attorneys
2. Organize as if you expect to see the report projected onto a giant screen in a courtroom
3. Assume that the person reading your report knows nothing about anything that happened while you were on the scene
4. Make sure the reader knows WHY you didn’t treat or transport
5. Presume nothing and leave nothing [relevant] to the imagination

Patients not transported

As I have said and continue to say, the calls in which there is a patient who refuses treatment and transport are the most dangerous calls of all. There are times when a patient’s refusal is acceptable, but the fact remains that the audience for your documentation is most likely to be a lawyer who wants something from you because something bad happened after you left.

The BIG Five

1. Write for the attorney who is suing you over this call (sad, but true)
2. Organize as if you expect to see the report projected onto a giant screen in a courtroom — because it will be
3. Assume that the person reading your report (and the jury) knows nothing about anything that happened while you were on the scene
4. Make the reader understand WHY you didn’t treat or transport
5. Presume nothing and leave nothing [relevant] to the imagination

As you can see, knowing the audience for your documentation is as important as everything else an emergency provider has to do, perhaps more so if knowing the audience leads to greater diligence and better care.

This article, originally published on June 2, 2011, has been updated.