DOCUMENTATION The Patient Care Report, avoiding liability and winning lawsuits The Paramedic & EMT legal duties To the patient To the employer To the Medical Director To the Public LEGAL DUTIES DEFINED Statutes and Regulations – Based on accepted Standards of Medical Care 2000 AHA ECC Guidelines Lee County Medical Protocols Florida Department of Health-Bureau of Emergency Medical Services – Chapter 64-E, Florida Administrative Code Licensing, Certification, Permitting Medical Direction Records & Reports Pre-hospital Requirements ETHICAL RESPONSIBILITIES Responding with RESPECT to the physical and emotional needs of every patient Maintaining mastery of skills Participating in continuing ed/refresher training Critically reviewing performance and seeking improvement Reporting honestly Working cooperatively & with respect for other emergency workers and health care professionals LIABILITY Failing to perform EMS duties appropriately can result in civil or criminal liability LIABILITY The best legal protection is providing appropriate assessment and care coupled with accurate & complete documentation LAWSUITS LAWSUITS A vehicle stalls on a bridge and its occupants leave to obtain help. Their empty vehicle is struck in the rear by another vehicle. They get back inside before the police arrive. They claim injury from the collision LAWSUITS A wedding guest at a reception sues his dancing partner for causing his ankle injury, even though a video tape shows the “victim” dancing through the evening without a problem. LAWSUITS An intoxicated driver traveling over 75 miles per hour causes a multi-vehicle accident. He sues the driver of every other vehicle involved. He also sues responding police, fire and medical personnel for negligent treatment of his injuries. LAWSUITS An increasing number of suits are in fact without merit and even fraudulent. It is therefore important to be in a position at all times to counter even the unexpected. The key is PROPER DOCUMENTATION LAWSUITS RATIONALE FOR DOCUMENTATION Legal – CYA – State requirements Q/A – Educational – Review for need to change Procedures Equipment SOGS RATIONALE FOR DOCUMENTATION Statistics – Justify budgets – Justify personnel – Justify needs – Awareness of problem areas Others CURRENT LEGAL CLIMATE Most emergency responders believe there is little chance of being sued Lawsuits for negligence are few in comparison to the the number of agencies in the country What the stats do not show are the numerous incidents of internal disciplinary hearings, claims and lawsuits filed that result in unrecorded disciplinary action or monetary settlement CURRENT LEGAL CLIMATE Just being called in as a witness can be embarrassing and degrading Your intelligence, integrity, character and competence may be challenged throughout the process PROACTIVE APPROACH Most negligence suits against emergency responders that are successful, either by way of settlement or verdict, are the result of a lack of preventive maintenance PROACTIVE APPROACH One critical area is that of creating standards for report writing An injury victim’s attorney will request by letter or subpoena, administrative records, run reports or medical narratives. PROACTIVE APPROACH A poorly written report may fail to document that the responder followed proper treatment and response protocols This may result in the responder and/or his agency becoming potential defendants All documents should be written in the knowledge that they may be analyzed for potential negligence SOP’S / SOG’S SOP-procedures that require mandatory compliance SOG-the requirement is a goal to be achieved under the best of circumstances SOP’S / SOG’S If you decide to deviate from protocol assure: – That SOP has already been followed and they have not worked – Something other than SOP’s must be done – You have contacted an “up-line expert” and informed him that operating procedures were followed, that they failed, and that he wishes to make a deviation – You receive specific permission to proceed and has documented the entire communication in your run report DOCUMENTATION You know exactly what happened You know why you did it If you have to tell your story to those that question you, you will be vindicated DOCUMENTATION You won’t be asked to give your version until someone else has already complained and given their version Whatever you say will be “in response” to someone else’s version and will and will be suspect since you have a self-serving motive DOCUMENTATION What you must do is to protect yourself each and every day in each and every incident that has the potential for trouble by telling your story in a form that the law will recognize as highly believable and persuasive Written documentation is not the best way to get your story across……….. IT’S THE ONLY WAY!! DOCUMENTATION It is not just important to document thoroughly, it is often LEGALLY CRITICAL! In virtually every controversial situation, before you get the opportunity to relate the story, the complainant has been heard, the records have been checked and often, minds have been made up as to who was wrong and who was right. DOCUMENTATION Before you are challenged, make sure that your reports are……. – Right – Complete – Persuasive They are your voice long before you get a chance to speak DOCUMENTATION If you saw it,heart it, smelled it or thought it…… – WRITE IT DOWN! THINK! If your instincts tell you that the item is probably important, then it probably is………. – WRITE IT DOWN! Tell what you sensed, why you felt it was important, what you did in reaction and why DOCUMENTATION Stay away from conclusions and opinions Stay as factual as possible Do not report that people were “drunk”. Do not use words like “wreaked” of alcohol – Use- “There was a strong alcohol-type odor” – Use- “He slurred his words” 10-COMMANDMENTS OF DOCUMENTATION RULE 1 – IF YOU SENSED IT, WRITE IT If you saw it, touched it, smelled it or heard it, it should be recorded. Be specific If instincts tell you it is relevant or important, it probably is 10-COMMANDMENTS OF DOCUMENTATION RULE 2 – WRITE IT IN A TIMELY FASHION As soon as practical In the courts, a record that is not timely is less trustworthy due to fading of memory over time 10-COMMANDMENTS OF DOCUMENTATION RULE 3 – BE NEAT AND LEGIBLE It’s appearance, it’s legibility, it’s ability to be easily understood is a reflection on the person who prepares it Neat, legible writing carries more weight If the report is not typed, print Use black ink for durability and legibility Proper spelling helps integrity NEAT & LEGIBLE 10-COMMANDMENTS OF DOCUMENTATION RULE 4 – BE COMPLETE The reader should be able to view and feel the scene as you saw and experienced it. What was the time constraint? What was the urgency? 10-COMMANDMENTS OF DOCUMENTATION RULE 5 – BE SPECIFIC Use quotes when applicable But, make sure it makes sense 10-COMMANDMENTS OF DOCUMENTATION RULE 6 – SUPPLEMENT Additions to reports in order to add information originally omitted is not only acceptable but reasonable State the reason for the original omission – Error – Did not seem relevant at the time – Not known and came to light later Should be dated and time stamped Do no cover up that it is supplementary 10-COMMANDMENTS OF DOCUMENTATION RULE 7 – AUTHENTICATE AND PUBLISH Initial and date all changes or additions to original reports with notice to all who may have received a copy. 10-COMMANDMENTS OF DOCUMENTATION RULE 8 – DO NOT ERASE PRIOR DATA If a change is made to an original, it should be clear what was changed White-out should NOT be used If a word is being changed, there should be a single line through it, and the correction should be made next to it The change should be initialed and dated 10-COMMANDMENTS OF DOCUMENTATION RULE 9 – USE UNDERSTANDABLE TERMS It is acceptable to use words and phrases commonly used in the profession Avoid abbreviations when possible – If using, use standard abbreviations 10-COMMANDMENTS OF DOCUMENTATION RULE 10 – READ WHAT YOU WROTE If there is the shadow of a doubt as to whether it is clear, revise it now READ WHAT YOU WROTE! “Patient has chest pain if she lies on her left side for over a year” “She has had no rigor or shaking chills, but her husband states he was very hot in bed last night” “The patient has no past history of suicides” “The skin was moist and dry” READ WHAT YOU WROTE! “Gators To face Seminoles With Peters Out “ – (The Tallahassee Bugle) “Alzheimer’s Center Prepares For An Affair To Remember” “Gas Cloud Clear Out Taco Bell – (Miami Herald) YOUR STATE OF MIND May determine the report’s quality – Complacency – Fatigue – Burn-out – Sour attitude – Poor work habits YOUR STATE OF MIND The one that burns you may be…… – The routine drunk – The “frequent flyer” – The nursing home call – Signal 4 in the rain, etc. FIRST RESPONDERS Record any treatment given by anyone who initially rendered care, improper or not You must identify them, if possible and their level of expertise AUDIO TAPES Audio tapes are becoming as critical as the run report itself – Reflect what actually happened – Reflect the attitude of the speaker Sarcastic tones, tones indicating anger, complacency or indifference that are played in front of a judge or jury can damage your credibility BASICS OF A RUN REPORT Chief Complaint History of present illness/injury Physical exam Past medical history Current meds Allergies Treatment BASICS OF A RUN REPORT Chief Complaint – Primary problem or complaint – Use patients own words only if applicable BASICS OF A RUN REPORT History of present illness/injury – Onset of symptoms – Provocation – Quality of pain or discomfort – Radiation? – Time symptoms began – Associated symptoms Other signs present – Associated factors Mechanism of injury, speed, objects, etc. BASICS OF A RUN REPORT Physical exam – Head to toe survey BASICS OF A RUN REPORT Past medical history – Patient’s pertinent medical history BASICS OF A RUN REPORT Current meds – Any pertinent meds – Document if meds given to LCEMS BASICS OF A RUN REPORT Allergies – Meds – Latex – Tapes BASICS OF A RUN REPORT Treatment – All treatment rendered to the patient Include times in sequential order Note changes – Improve – Worse – Same Number of times attempted to tube or start IV and at what point it became successful or not BASICS OF A RUN REPORT SAMPLE – Symptoms – Allergies – Medications – Past medical history – Last oral intake – Event leading to injury or illness BASICS OF A RUN REPORT OPQRST – Onset – Provocations – Quality – Region or Radiations – Severity – Time BASICS OF A RUN REPORT DCAPBTLS – Deformities – Contusions – Abrasions – Punctures – Burns – Tenderness – Lacerations – swelling BASICS OF A RUN REPORT Make it complete Make it honest Make it simple Review it Be Professional QUIZ FOR PROFESSIONALS The following quiz tells weather you are qualified as a professional or not. QUIZ FOR PROFESSIONALS How do you put a giraffe into a refrigerator? – Open the refrigerator, put in the giraffe and close the door. This questions tests weather you tend to do simple things in an overly complicated way. QUIZ FOR PROFESSIONALS How do you put an elephant into a refrigerator? – Open the refrigerator, take out the giraffe, put in the elephant and close the door. This tests your ability to think through the repercussions of your actions. QUIZ FOR PROFESSIONALS The Lion King is hosting an animal conference. All the animals attend except one. Which animal does not attend? – The elephant. The elephant is in the refrigerator. This tests memory. QUIZ FOR PROFESSIONALS There is a river you must cross, but crocodiles inhabit it. How do you manage it? – You swim across. All the crocodiles are attending the animal conference. This tests weather you learn quickly from your mistakes. QUIZ FOR PROFESSIONALS According to Andersen Consulting Worldwide, around 90% of the professionals they tested got all questions wrong. Many preschoolers got several correct answers. This conclusively proves the theory that most professionals have less brains than that of a four year old.
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