Documentation

[Guest guest]

From time to time I am asked to review cases that are involved in litigation.

I usually have two or three going at any one time. There are many other

paramedics who engage in expert witness work and they say the same things I'm

getting ready to say.

A recurring problem is that of documentation. As much as we preach

documentation, people still do not document standard of care. They do not

document

an adequate assessment. They still do not write a narrative that will explain

what they did and why. Often I can see that they did the right things for

their patient, but they didn't bother to tell me in their patient care report in

a way that cannot be ripped apart. We win cases for medics and EMS services

when documentation clearly shows adequate assessment, the patient's

conditions, and that standard of care was delivered. We lose or have to settle

when

the records do not reflect those things.

Also, I often must ask the medic who wrote the report to " interpret " it for

me because I cannot read the writing. Pertinent times are not put in, fields

are not filled out, and an adequate assessment is not documented. Sometimes

abbreviations are used that are ambiguous. SOB can mean short of breath or

an opinion of the patient's character and lineage.

While checkbox forms are helpful up to a point, there is no substitute for a

nice story that will tell the jury exactly what happened, what you did, why

you did it, and how the patient responded.

Electronic charting is now reasonably available for almost any service, even

the ones with limited resources. I cannot imagine why all services are not

using it. At least one can read what's written. Those programs can make it

impossible to complete the report without at least filling out all the blanks.

The reasons people get sued are not always apparent at the time of transport.

Two years later when you're sued for a patient you thought was routine, you

were in a hurry, and you scribbled out a report that managed to get past QA,

and now neither you nor I as your expert can figure out what happened from

your report.

Do those of us who try to help you a favor and give us documentation that's

complete, write a nice, concise narrative that tells the story (Once upon a

time there was a little old lady who had chest pain...) that the reviewers and a

jury can understand, and make sure you document that you provided standard of

care.

Of course, if you don't know what standard of care is, that's another issue

entirely.

Remember that if you get sued, your patient care forms, your billing

documents, and your deposition will be filed in court, available for anybody to

see.

Just the other day a newspaper reporter called me about a case I worked on

over 5 years ago. He had pulled out the court file and read it, and he was

irate about the quality of the patient care report that was filed. He asked

this question, " What is the educational level of the person who wrote this? "

I hope we don't see that report in USA Today soon. And no, it's not covered

by HIPAA once it's in evidence in a legal proceeding.

GG

Gene G.

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