There is never 'Nothing' to write

As society becomes more and more litigious, EMS providers face greater and greater risk by not fully documenting their calls

On a cold February night, a paramedic unit is called to the drug store parking lot for an assault.

They arrive on scene at about 2:00 a.m., just 8 minutes after being rousted from a comfortable, warm sleep. The store is closed, the lights are off, and the doors are locked. There is not a soul in sight — there is nothing showing.

Dispatch advises that it was a single caller and the police department has no additional information. A quick check of the surrounding area provides no clues. No blood drops, no evidence of anything.

The paramedics drive around the store with spotlights blaring. Nothing.

They advise dispatch that they do not see anyone and declare themselves available. They hope to be comfortably sound asleep again in a few minutes.

As they come to a stop back at the station, the documentation of the call is complete. The form contains times, location, crew member identification and, in giant letters that consume the entire narrative section, there is only this: "U.T.L." (Unable to Locate).

By 2:30 a.m., the medics are once again basking in the warm comfort of slumber.

Every EMS call requires complete narrative documentation

Anyone who has worked in EMS for more than five minutes has been on this call. Unfortunately, far too many have and continue to put themselves at significant risk of [undeserved] liability by simply documenting the inability to locate rather than including everything [they] did to search for the patient.

If you have been reading this column for any length of time, then you know I have been preaching for years that there is NO call that doesn't require full and complete narrative documentation.

Sadly, I still encounter resistance from old-school providers who have been doing it like that forever and don't see any need to change now. I have bad news for you old-schoolers: times have changed and you are headed for a very rude and very expensive awakening.

You can not defend 'Unable to Locate'

As society becomes more and more litigious, EMS providers face greater and greater risk. Risk of falling victim to attorneys who are paid hundreds of dollars per hour to make you look incompetent, stupid, and careless, and "U.T.L." makes their job very easy to do.

It goes something like this: Imagine the same scenario, but with this twist: At 10:00 a.m., eight hours or so after the call, the assault victim is found dead behind the drug store. The family learns that there was a 911 call and that you responded to the call. The attorney they hired for the multi-million dollar wrongful death lawsuit subpoenas your run report. The report says nothing about what you did, rather it simply says: "U.T.L." or "No Patient."

At the deposition or in the trial, the attorney will grill you. They will start by asking whether you have ever attended a documentation class. You will say yes.

Did you learn that documentation must be thorough? Yes.

Did you learn that documentation should summarize everything that was done on a particular call? Yes.

Are you familiar with the adage, "if you didn't write it, you didn't do it?" Yes. And so it will go.

Then it will get worse. The attorney will hit you with questions that are impossible to answer in a way that doesn't make you look like a fool. They will ask whether your documentation contains everything important about this particular call. If you say yes, you didn't search. If you say no, they will remind you that you just said that documentation should summarize everything that was done.

Now, your documentation is incompetent and below standard — and so are you. Suddenly, your "U.T.L." or "No Patient" translates to "You didn't take reasonable steps to search for the victim and, because you did not do your job, now he is dead." The even sadder reality is that this argument doesn't have to be true, it only needs to be convincing.

Thankfully, this risk is easy to avoid altogether. On every call, no matter what happens, write a full and complete narrative that leaves no relevant fact to the imagination. Include what you saw, what you did, who you talked to, and how you left it. Let there be no doubt that you did every reasonable thing.

Otherwise, you don't get to cry when your own lack of words is twisted such that you lose everything.

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