DOCUMENTATION by xiangpeng

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									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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