Five Good Reasons for Better EMS Documentation

[tskstorm]

http://publicsafety.com/article/article.jsp?id=2468&siteSection=7

[emtannie]

I was a little surprised to see that the article was dated 2005. This is a topic that should be reviewed regularly! I get so tired of seeing shoddy reports.

Our service does internal audits - every member has to do a minimum number of audits of other people's reports each month. The author of the reports is kept anonymous and the supervisor assigns them to each crew member. (The supervisor can tell who wrote each report, so can ensure that you aren't auditing your partner, or someone you are close to, to maintain objectivity). There is a criteria for audit, which isn't very hard to follow. One of the advantages of this, is it forces people to see others' reports, and they can see reports that are awful, and those that are really well done. They can see errors where they go "oops, I know I do that too" and can self-correct, or help guide someone else to write better reports.

One of the things we noticed when we started this type of audit system, was the number of times we reviewed a report where we questioned interventions. For example: "the patient had chest pain, and it wasn't an inferior MI based on monitoring, so why weren't they given ASA and nitro?" The system allows the auditor to ask the question (again, anonymously) and the person who wrote the report can respond to it. It is scary how many times it comes back "I did give nitro and ASA, but it isn't in the report.."

With this in place, some of our staff are taking more time and being more diligent in their reporting. Having had to attend my first court case where both my report and I were subpoena'ed, I am glad that my report for that call was very detailed, and I know I review my reports more carefully since that experience.

Good link, tsk - thanks for posting it.

[tskstorm]

Yup its always good to review!

[Alex Woo]

Too bad the NYS DOH EMT-B/I/CC/P programs do not really go over PCR/ACR documentation. They always emphasize that if you didn't write it, you didn't do it. PCRs must clear, concise, & complete. It is a legal document. That's it..

I QA/QI and do individual Call Review w/ my guys. Many are new to 2yr EMTs and they state they never learned how to write PCRs. So its a long and difficult process.

Thanks NYS DOH EMT Curriculums and Programs for the inadequately trained PHC Providers. The PCR are full of accronyms and neumonics. +ABC, +PMSx4, L/S clear & equal, -SOB, -Bleeding, -Pain, -DCAPBTLS, -JVD, -DNR, -Nausea, -Trauma, etc. Ok, what's wrong w/ the pt then? Again, kudos NYS DOH EMS.

Plz read my thread regarding NYS EMT Certification Restructuring... Thx...

[Richard B the EMT]

It is scary how many times it comes back "I did give nitro and ASA, but it isn't in the report.."

They always emphasize that if you didn't write it, you didn't do it. PCRs must clear, concise, & complete. It is a legal document. That's it..

As we are from the same EMS in the same state, you beat me to saying that, Alex. Lawyers eat for breakfast EMTs or Paramedics who don't document, and use that line

[Greed21]

I did some ride time on a primary 911 service in a city and i would witness some of the medics not taking BPs and every call i went on O2 was not givin to the patients! But they would write on the report O2 was administered and they would make up BPs and other information to fill it in! Scary...

[paramedicmike]

The PCR are full of accronyms and neumonics. +ABC, +PMSx4, L/S clear & equal, -SOB, -Bleeding, -Pain, -DCAPBTLS, -JVD, -DNR, -Nausea, -Trauma, etc.

Interesting you would complain about this given these other lines from your post:

Too bad the NYS DOH EMT-B/I/CC/P programs do not really go over PCR/ACR documentation.

and:

Ok, what's wrong w/ the pt then? Again, kudos NYS DOH EMS.

Nevermind the multiple uses of "w/" to abbreviate the word "with" outside what's been quoted.

I'd be interested to see what your charts look like after this post.

Plz read my thread regarding NYS EMT Certification Restructuring... Thx...

Wow! Look! More abbreviations and acronyms! Who'd have thought it would be coming. In self advertisement form no less.

Very interesting, indeed.

With regards to the OP, I'm constantly amazed at the lack of instruction in how to properly document a patient encounter afforded to EMT and paramedic students. I'm more amazed at the lack of basic spelling and grammar principles held by those writing the reports I QA.

[Eydawn]

I always chart like I'm going to have to defend myself with it in court. I'm a lot more verbose than some of my compatriots... and there's very few acronyms that I use. PCP for personal care provider, NOC for night... BM for bowel movement... and that's pretty much it. I write it out so that anyone else reading it could see exactly what happened.

It's amazing how you learn to phrase things... like "found on floor" is totally wrong... (you found them? So they were lost, eh?) lots of little things that can trip you up.

Wendy

CO EMT-B

[JPINFV]

As we are from the same EMS in the same state, you beat me to saying that, Alex. Lawyers eat for breakfast EMTs or Paramedics who don't document, and use that line

...and it's funny because the 'out' for physicians, as taught to us by lawyers when covering jurisprudence, when we forget to document something is the term "customary practice." If it wasn't written down, it may have happened, but a written record is a lot stronger than, "Of course I listened to lung sounds, even if I didn't mark the boxes."