Outside the Boxes: The Importance of Good Documentation
Documentation is one of the most important things done during and post patient care. It is your job to see that your EMS report reflects complete and accurate information, and that your patient care narrative covers more than just what the check boxes provide. Your report is a legal document and part of the patient's medical record.
With the narrative being so important, let's take a look at its contents under some different scenarios. Common pieces of information are sometimes left out.
1.) The run always starts at the time of dispatch and includes what you were dispatched to and what you found at the scene. For example: "Dispatched for a person in seizures. Upon arrival found 35-year-old female lying supine in bed in bedroom at place of residence. Complaint of chest pain." Starting out every report the same way builds consistency. This example covers what your detail was for and what you found when you got there, and also describes the position in which your patient was found and the type of distress she was exhibiting.
2.) Another common omission is information about auto accidents. A good description of the scene is required in these cases, especially with the possibility of lawsuits to follow. "Upon arrival found two-vehicle MVA, head-on collision with heavy front-end damage to both vehicles and confirmed entrapment. Vehicle found upright with interior not intact and spiderwebbing of windshield. Also found air bag deployment, no seat belt used by patient." This describes the scene and MOI, and paints a nice picture for hospital personnel. Knowing what the patient went through helps guide their care and search for further injuries.
3.) The importance of thorough documentation with patient refusals cannot be stressed enough. These have a high probability of coming back to haunt you if information is left out. "Patient was advised to be seen at medical facility and advised of the possible consequences of not being seen. Patient refused treatment and transport, and signed refusal." This protects you, showing that you asked the patient to go to the hospital and advised them what could happen if they went untreated. How many times are EMS providers called back to the scene for the same patient and find them even sicker than they were? What happens then? The family wants to know why your crew didn't take the patient to the hospital the first time. If something like this goes to court, the report must show that you asked the patient and advised them of what could happen otherwise. Don't leave out a description of the patient and their signs and symptoms; a refusal of transport is not an excuse not to write a complete narrative.
4.) Assessments: Describe your patient fully from head to toe. Beyond what was found wrong, include other signs and symptoms, even if nothing was found. Including these establishes that you were also looking for other things wrong and shows that a full secondary exam was completed. Don't forget to add comments made by the patient or any observations of actions that could be out of the ordinary. Place patient comments in quotations or prefix with Patient states. This shows the information comes from the patient and not the provider assuming something.
5.) Treatment: Document all treatments performed or attempted, even those that were unsuccessful. Remember, if it's not documented, you didn't do it! This entails medications given, procedures performed and reassurance to the patient. Yes, you should state in your report that the patient was reassured--that's a form of treatment. Remember bedside manner? It's something learned in the back of the ambulance, not any textbook. Bedside manner is a form of customer service that can give your department a black eye if not handled properly. It can be assessed by your quality assurance division through use of customer service feedback cards mailed to patients after their care. It will let you know how your customers think they're being treated and how happy they are with your service. Customer service goes a long way when a levy for emergency service funding is introduced in your community.
6.) Transport: When documenting transport of a patient, consider something like: "Patient taken to [facility name] at their [parent's, etc.] request. Patient transported without incident. Monitored throughout, with no changes in condition noted during trip. Upon arrival, met by ED staff, report given and patient care transferred to ED staff, room #8 at 1300 hours." This shows where the patient was taken, that care continued during transport, and any changes in patient condition. This statement also shows that your patient arrived at the emergency department, you gave your report, and patient care was transferred to a hospital authority. The time may not seem like a big deal, but there have been court cases claiming abandonment by the EMS crew because their report didn't specify that another medical authority took over from the EMS crew and at what time.
Say you transfer the patient and are back out making the cot and readying the ambulance for the next call. In the room where you left them, the patient gets up from the bed to go to the bathroom, and the nurse steps out to get some supplies. While the nurse is gone, the patient falls and has a seizure. When the hospital is the bull's-eye for a lawsuit, the nurse can come back and claim patient care had not yet been transferred. Hence, also get a signature from the person taking over medical care. Now it's a done deal. They signed for the patient prior to the incident, the time is documented, and the EMS crew is cleared of involvement.
Also document any personal items that were transported and left with the patient (e.g., watches and other jewelry, dentures, canes, medications, etc.). These items are often misplaced or accidentally thrown away at the hospital, and if you can't show they were in the hospital's possession, who's the next to blame? You are.
7.) If you forget something that should have been in the report, write an addendum and include the date, time, patient name, run number and information you're adding. See that it stays with the original report.
There are a few different ways of writing EMS reports. Practice each form of documentation and see which fits you best. Read other narratives and study colleagues' writing styles before developing your own. If your department has a required form of reporting, know it and live it. Maintaining a standard report policy helps maintain consistency throughout the department and will assist in policing written reports. Develop your own style of writing within that form and build on it. Always be accurate and thorough. If a check box in your report doesn't pertain to the case, don't just leave it blank; draw a line through it. This shows you have acknowledged every piece of your report for that patient.
Training on documentation and reviewing your department's run sheets should be priorities. Incorporate this type of training on a regular basis. Your quality assurance staff should assist. In fact, the QA division should be your department's biggest advocate of complete and proper documentation. Reviewing reports is proactive, not punitive. Personnel should know that feedback on their reports is constructive criticism. Take the time to read your feedback and use it as a learning tool.
The documentation of your treatment of your patient should show that you have met all required standards of care. Leave no stone unturned when documenting. It is a form of risk management for any EMS department.
Lt. Les Allen is a firefighter/paramedic with the Loveland-Symmes Fire Department in Loveland, OH.