Five Good Reasons for Better EMS Documentation

Documentation, like any clinical intervention or manual task, is a skill that can be taught, practiced and improved upon.

Stark evidence of the importance of EMS documentation in the continuum of care can be found in a 2002 court case where the completeness of an ambulance crew's PCR was the central issue. According to the court's unpublished decision in DeTarquino vs. the City of Jersey City (NJ), a young man was involved in an altercation with police officers, subdued and taken to the police station. The officers subsequently called EMS to the station because of the patient's apparent injuries. During the course of EMS treatment and transport, the patient reportedly vomited. However, this fact was allegedly not documented on the PCR. The receiving facility to which the patient was transported-a community hospital emergency department-evaluated and discharged him. The patient was returned to police custody. At the police station, he subsequently developed a grand mal seizure. EMS was called again, and this time the patient was transported to a trauma center. He was later pronounced brain dead, and the cause of death was determined to be epidural hematoma.

Following the patient's death, his family brought a lawsuit against, among others, the ambulance service and the individual EMS providers. Their legal theory was that the EMS crew was negligent-not in its patient care, but in its documentation. If, they argued, the EMS crew had documented the fact that the patient vomited, as the family claimed, the first hospital might have recognized this as a sign of a potentially serious head injury, and might not have discharged the patient. The state's court of appeals agreed, and held that the state EMS Act immunity provisions did not protect providers from negligent documentation-only from negligence in the actual performance of patient care.

While the DeTarquino case is applicable only in New Jersey, it is instructive on the importance of accurate documentation from the clinical perspective. It also emphasizes the importance of writing a complete EMS chart.

In addition to the clinical uses of EMS documentation in the real-time rendering of patient care, documentation also serves another vital clinical purpose: the assessment and improvement of that care in the future. Documentation is central to quality assessment and improvement activities in EMS. It is our ethical imperative (as well as our legal duty in most states) to participate in a QA or QI process so that the effectiveness of our care can be continuously monitored and improved.

Legal: CYA
Of course, EMS documentation serves an important legal purpose. In the event of a lawsuit like the DeTarquino case discussed above or any case alleging patient care malpractice by EMS providers, your documentation will invariably be among the first things reviewed. The central issue in a malpractice case will be whether the EMS providers met the applicable standard of care. The EMS PCR will be the best record of that fact. It should also be a contemporaneous record of that fact. This means the PCR should be written at or as close to the time of the incident as possible, thus constituting the most timely record of your care. A contemporaneous PCR is usually more reliable than a provider's memory when sitting on a witness stand months or years after the fact.

One of the first things that most plaintiffs' attorneys will do when assessing a possible malpractice case is to review the documentation of the potential defendants, including the EMS providers. Most often, this review will occur in consultation with an expert witness, such as an emergency physician retained to help guide the attorney through the clinical appropriateness of the care and documentation. If an EMS chart is thorough, well-documented and reflective of the appropriate standard of care being satisfied, a reputable expert witness may well advise the attorney that there is no viable case to be had against the EMS providers. While it is often unlikely that a good PCR will "scare away" a plaintiff's lawyer, it is a possibility, especially when coupled with the hurdle of legal immunity for acts of ordinary negligence that EMS providers in most states enjoy.

From the legal perspective, EMS documentation should also be thought of as the provider's "substituted memory." In most states, the plaintiff has a fairly long period of time after the incident to initiate a lawsuit. This period is set forth in the statute of limitations. While it varies from state to state, the statute of limitations is most often measured in years (often two years). Memories can fade quickly though, and recollections of patients can blend together-especially after a few hundred calls. A well-written and descriptive PCR that creates a clear picture of the patient can trigger your memory of other important details of the call that are not documented on the chart.