I have never understood the seemingly pervasive and utterly inexplicable resistance of many EMS providers when it comes to documentation. Even more puzzling – and, frankly, alarming – is the combination of reticence and apathy to documenting non-transports.
When you transport a patient to the hospital, you also transport the liability associated with not transporting. That is, you are also transporting and delivering to the emergency department the headaches that come with leaving a patient on scene.
Non-transports are the most dangerous calls
Of course, not all patients want or need to go to the ED, yet, more than any other type of call an EMS provider can run, the non-transport is singularly the most dangerous.
Imagine being on a call where you have total control of the scene, the patient, the circumstances, and the disposition. You get to assess, treat and coordinate the most appropriate outcome in the best interest of the patient. Your professional expertise, leadership and control make the system work.
Now, imagine having that control and then just … letting it go; giving it away to the universe for whatever will happen to happen.
No provider in their right mind would do that, would they? Of course they would. It happens all the time; not every patient wants or needs to go to the hospital. Your professional expertise, leadership and control in those situations are exactly how the system is intended work.
It should come as no surprise to learn that civil, and some criminal, courts across the United States are flooded with cases alleging malpractice, neglect and even abandonment by EMS providers stemming from calls where the patient was not transported – whether transport was necessary is only a secondary issue.
It should also come as no surprise to learn that poor documentation is a common element in cases where the provider is found liable. On the other hand providers are less likely to be found liable in cases wherein the documentation is complete and accurate.
This should be a no-brainer. But, for so many providers, it’s not.
Know your audience for a non-transport PCR
Quality improvement auditors notwithstanding, every patient care report is written for a particular audience. Continuity of care dictates that the audience for a PCR written on a patient who is transported is the medical staff who will be caring for the patient long after the transport is done.
Likewise, the audience for a PCR written on someone who EMS finds to be deceased is the medical examiner and/or homicide investigators.
Lastly, and none too ironically, the PCR written on a patient (or person) who is alive and not transported are the lawyers; because someone is saying that YOU did something wrong.
Regardless of the audience, each is looking for the same four basic elements:
- The provider’s awareness of the actual circumstances underlying the call
- The assessment and findings
- Whether associated policies, procedures, and protocols were followed
- Whether appropriate treatment was delivered
These elements contain the most important pieces of information the reader needs; continuation of care, determinations about cause of death, or establishing that care was appropriate and consistent with the recognized standards. Everything beyond these four elements is fluff.
As it relates to the patient (or person) who is not transported, everything necessary for a lawyer to prosecute or to defend the provider in court – or before an administrative board or other adjudicating body – will be established by the presence or absence of these elements in the PCR.
Tell the whole story in the PCR
As it is for all PCRs, when documenting a non-transport, tell the whole story; what you did, what others did, what you said, what others said, what you saw, what others claim to have seen and, most of all, what you did to convince the patient to accept transport to the hospital and what the patient said in response.
Review the PCR before you submit
It’s not enough to simply read it over to make sure you like what you wrote. Take a minute and shift perspective; review it from the perspective of the intended audience. Remember that they will only know about the patient and the call from what you wrote in the report.
Have the patient sign the narrative
Every agency has an Against Medical Advice page or paragraph for the patient to sign. Unfortunately, AMA statements are written by lawyers and most are incomprehensible to any person unfamiliar with legalese.
It is my opinion that undoing them in court is pretty easy:
Lawyer: “Did you understand what you signed?”
Patient/Witness: “No.”
Lawyer: “But it says right there that you understood what you were signing. Now you are saying you didn’t understand?”
Patient/Witness: “They just said sign here, so I did. I didn’t really have time to read it and I didn’t even have my glasses.”
Lawyer: “So the paramedics made you sign something you didn’t and couldn’t even read?”
Patient/Witness: “Yes.”
There is an easy fix for this problem: have the patient sign the narrative.
Also, not all non-transports are AMA. Some folks simply don’t have a problem that requires transport to an ER. That’s okay too. Everyone signs the narrative!
When the narrative clearly and concisely shows that the paramedic understood the actual circumstances that brought them to the call; AND that they performed a thorough assessment; AND that they understood the various policies, protocols, and procedures associated with the findings of that assessment; AND that they did everything appropriate to counsel the patient or outright convince the patient to go to the hospital (as indicated), including possible consequences of not going; AND they have documented that the patient proved he or she understood all of the foregoing by repeating it back to the paramedic, then the patient signs the narrative acknowledging and attesting to the truth of the foregoing transport.
When the narrative is clear and signed by the patient, it will be exceedingly difficult for that patient to come into court and say he didn’t understand. That is, it will be extremely difficult to prove that you did anything wrong.
ePCR hurdle to patient signing the narrative
Many if not most providers have transitioned or are transitioning to ePCRs and most ePCR platforms don’t allow for a patient to sign the narrative. If that’s that case, I recommend that your agency come up with some kind of bridge fix until your ePCR provider can create that ability.
Resistance to the patient signing the narrative
Signing the narrative is a cornerstone of the EMS Documentation lectures I have been giving for years. Nevertheless, even when I explain why, EMS providers commonly tell me they are too busy to do all of this documentation work for a non-transport.
My response to them is simple: You have a choice. Either do what is best for the patient (and for you) with thorough documentation, which includes a patient signature on the narrative, or start saving for legal representation.
