How to Elite: General Documentation

How to Elite: General Documentation

The latest “How to Elite” installment will cover documentation of your patient encounter in a general manner.

First, every EMS incident requires a report.  If all EMS and Fire units are cancelled, the ambulance will complete the report.   If someone arrives on scene, the unit onscene or AIC will complete it.  All reports are required to be completed within 12 hours of the case per State regulation!   Reports should be 100% complete with no less than 98%.  Reports lock within 36 hours of posting.  After 36 hours, any corrections or additions would need to be added as an addendum.  Instructions  and report deadline information can be found here: https://www.vbems.com/2017/04/10/patient-report-deadlines-and-when-to-do-one/

Patient reports may seem annoying and cumbersome but are legal documents.  They are viewed by physicians and hospital staff who base their care on what they see, the medical examiner, lawyers and even the patient or their family.  They are reviewed internally and data can be shared with external parties for research, training, administrative functions and reviews.  Report data is also exported to the state.

Many reports are posted with just enough information to satisfy the 100% validation but no real substance.  This is technically ok if the minimum criteria are met but if you have to go to court five years from now, will you remember the case based on your documentation?  Will the physician reading the report looking for clues be able to understand what you found and did?  If this report was written about you or your family member, would you be ok with the information it contains?  Stick to facts of the case and leave out extraneous information that doesn’t apply such as a disagreement with the doctor’s office staff.

Common missing information includes procedures performed, medications given, assessments and reasons for doing or not doing things.  If you do not directly follow the protocol, the report should reflect the thought process behind it.  For instance, if you do not administer ASA to a cardiac patient because they are vomiting, you should mention that.

Contradictions and inconsistencies in the report itself are huge red flags.  Examples of missing and inconsistent information include things such as:

  • Narrative mentions a medication was given but not listed in the medication section (with the dose, time, person giving, etc.)
  • Comments indicate drug use and paraphernalia but the box for drug use indications states none.
  • Items requiring physician order are labeled as standing order
  • Times for medications or procedures are misaligned
  • EKG and 12 lead data not uploaded
  • Standard protocol medications or procedures not mentioned at all
  • Unknowns listed instead of pertinent patient data

Patient care reports directly reflect your actual patient care.  If it is inconsistent, people reading it may easily assume your care was just as inconsistent.  Being consistent with your documentation helps you to prevent omissions and actually decreases your writing time.

Everyone develops their own style of reporting over time.  Be consistent, accurate and timely!

Here are a few articles that you may want to review:

http://www.jems.com/articles/print/volume-33/issue-4/administration-and-leadership/write-it-rightkeeping-your-pcr.html

http://www.lifeunderthelights.com/2009/07/12/six-tricks-you-can-use-today-to-improve-your-ems-narrative-report/#sthash.FKWaQWMR.dpbs

http://www.emsworld.com/article/10323583/five-good-reasons-for-better-ems-documentation