Tell Me A Story

     Documentation is an important but often overlooked part of every EMS call. How much time does an EMS provider put into documentation? How much time should an EMS provider put into documentation? How detailed should the reporting be? Would your reports hold up in court? The answers, and some additional points as well, are important for every call you respond to.

The Basics
     Every EMS agency utilizes some method of patient care reporting. Some use standard forms created and distributed by governmental regulatory bodies (state EMS agencies), and some use forms they, themselves create to include specific information and data points. Agencies all over the country are now moving to electronic reporting.

     Regardless of the method of reporting, the majority of reports can be broken down into several categories, with possible variations within those categories. Each EMS provider should be intimately familiar with the reporting method his agency utilizes; the form and format of patient care reports will vary from state to state, and possibly even from locality to locality and agency to agency. Typically, these forms include spaces in which to write information, as well as dots to fill in. Remember that in most cases, the report is a legal document and an important part of patient care.

     For paper forms, it is usually advised that the provider completing the report use a ballpoint pen and apply firm pressure, as most reports have multiple copies. Handwriting should be clear and legible, and words should be spelled correctly. It is usually acceptable to use abbreviations, but which abbreviations, and for what conditions, should be clearly understood. Additionally, all blanks should be filled in, to avoid giving the impression that the report is incomplete-or, more important, allowing an opportunity for the report to be altered.

     When writing a report, it is important to tell the story of what occurred on scene. Be as specific as possible, and try to include things you see, hear, touch and smell. Many times the use of pertinent negatives-meaning ruling out things that may be typical of patients with similar illnesses-is important as well. These negatives could have a big impact on your treatment.

     Most reports will begin with general information: a report number, usually a report identifier for reference purposes, and the date (usually in MM/DD/YY or MM/DD/YYYY) format. Always remember to use leading zeroes to avoid blank spaces. For instance, to avoid the possibility of tampering, February should be documented as 02 instead of 2. There also will be places to provide agency information, either via a predetermined code assigned to the agency or by simply listing the agency in an appropriate space. There may be space for the specific responding unit (Medic 4, Ambulance 2) as well. A form will have spaces for the incident nature and location; it may even include latitude and longitude (for agencies that utilize GPS) or zip code. There may also be places to indicate the type of location where the emergency occurs (e.g., roadway, residence, healthcare facility), other responders on scene (fire, law enforcement, other EMS, facility staff) and call times. Call times may include the times of call reception, dispatch, response, travel, arrival on scene, arrival at the patient's side and in service.

     Next, most reports include some place to record information like the patient's name, address, spouse and/or guardian (if applicable). Phone number, date of birth, age, gender, weight and even race may also appear. A recent trend includes patients' social security numbers; this is to tie the prehospital report information to information gathered in the hospital. Additionally, the SSN is one of the main identifiers for NEMSIS (National EMS Information System) project data. Every effort should be made to obtain this information, even if it is just the last four digits.