It is no secret that firefighters and paramedics can find documentation of an incident challenging. We all know it can be a long and tedious process, especially at the end of a busy 24-hour shift. However, what first responders fail to realize in not documenting properly and completely is that they are not only bringing discredit to the medical profession they belong to, but they are also opening themselves up to a chance of serious legal consequences in the future.
Civil litigation is all too common today. Once that send button is pushed on the ePCR, the information entered into the computer is now permanent and available to be scrutinized later by any legal eagle acting in the best interest of their client. We have all heard of the word “omission.” This is a failure to do something, especially something that one has a moral or legal obligation to do. We all know what we are suppose to do. It is told to us daily, presented to us in training frequently, and reinforced by that little voice in your head during every call.
The facts are that every report should at the minimum reflect the basic details. Why? It’s simple. Today’s world is that of a litigious society. First responders and the agencies they work for are easy targets for civil litigation, especially in this world of multimedia. Hidden cameras are a common occurrence. They are not only out in the public, but they are also in the private homes of the public and on their persons. No matter where you are nowadays, you should always consider yourself under some sort of surveillance and act accordingly.
It should come to no surprise that if something goes wrong with a patient and a civil lawsuit is filed, the first thing the attorneys for the plaintiff will ask for is the documentation of the incident, the second will be any available recorded video. Once received, the attorney will surgically dissect the report, going line by line and pixel by pixel, looking for something he or she can use to bolster their case. Not only are they looking for things to use against you, but they are also looking for the things that are not there. Sometimes not putting the necessary information in your report can be more damaging than what you did place. If it is not documented in the EPCR, a smart lawyer will argue that it never happened. You may have done two complete sets of vitals on a patient but unless they are in the report, you didn’t do them.
No one knows this better than Captain Matthew Conroy of the LAFD EMS Bureau. He writes, “It is important for members to understand the reasons why good documentation is so important. The quality of documentation represents a direct reflection of the quality of care provided. If the documentation is thorough and meticulous, it is assumed that the patient assessment and treatment was also thorough and meticulous. On the other hand, sloppy documentation suggests sloppy care which erodes our reputation as quality medical providers to our hospital peers and could seriously damage our credibility in a courtroom setting.
“Despite our best efforts, it is inevitable that some of our patients will have bad outcomes
and our care will be scrutinized.”
While electronic patient care reports make some aspects of documentation easier, they also create opportunities for documenters to inadvertently contradict themselves. For example, we frequently see reports where the narrative and the “checkboxes” contain conflicting information. Anyone who has used ePCR software understands how easy it is to make these types of mistakes. However, these types of contradictions appear careless and can undermine the perception of how well the patient was cared for. Despite our best efforts, it is inevitable that some of our patients will have bad outcomes and our care will be scrutinized. When this occurs, our members should be confident that their documentation will properly illustrate the exceptional EMS care delivered to the public on a daily basis—Captain Matthew Conroy.”
An incident report is not only a storytelling of what happens on the incident, but it is also what didn’t happen. When documenting, a clear picture must be painted for future review of the facts. If the patient was having chest pain, did they have shortness of breath? This is an important fact to know. It is also a fact that will be checked into, along with many other examples, if the incident results in litigation later. Other important facts that must be documented but may not have a box to check or uncheck is what is verbally said on scene of the incident. Was the patient talking in full sentences or not at all? Did they say one thing that contradicts something else said by them or others? It may not seem important at the time due to tunnel vision on scene; however, it may be of importance in a case of litigation years later.
Today’s report writing is very different from the past. What was once a one-page paper report filled with boxes to check and a small section to document the facts is now a powerful computer capable of almost unlimited data collection. You have no excuse not to fully document the incident. You have had the basic training with the availability for additional training online and are only a phone call away from your EMS Supervisor to receive more. Once you arrive on scene, the documentation completed by you should give a clear and precise visualization of what the scene looked like, what you did while on scene, and what care you provided to your patient. If done correctly and completely, the information provided by you should correlate to the patient’s outcome. Effective, precise documentation will not only give you a better chance of memory recall if called upon in a civil litigation, but it will also be the key in avoiding it in the first place. Remember: If it is not written down, it didn’t happen. So, take the time to thoroughly document as if your career depends on it—because it just may!
By John Hicks