Do you document the race of your patient ?

[Richard B the EMT]

I believe some are confusing race with colour. To describe someone as black or white is absurdly ambiguous. I prefer the actual racial labels, such as negro or caucasian.

A good point. I know some folks who are pasty white in midwinter, but get so tanned in the summer, that some white supremicist "skinheads" driving by, called them by one of the derogatory terms used by such as them as put-downs for "African-Americans" (the "N" word). Also happened to me, several decades ago.

[Chief1C]

This topic seems to have been clubbed repeatedly in the head now... let's talk about something fun that we can all agree on like firefighting 101: fire bad, water good... or firefighting 201: more fire bader, more water gooder...

Lol... sorry...

http://www.firefightercity.com/

[sirduke]

Yes, but only because we use the ART system on our laptops and it is required to validate the report.

[KATIE]

i work in the ed in our local hospital and we always ask for what race the pt considers themselves to be. it can be very helpful in interpreting lab results. i also work in the lab at the hospital and different races can have a difference in lab values.

[flamingemt2011]

I think the OP was talking about documenting it in your narrative, not in the data fields that most states require for statistical analysis. I do not see any reason to doucument the race in the narrative if you have already indicated it in the data field as race does not change your treatment plan.

[Dustdevil]

I do not see any reason to doucument the race in the narrative if you have already indicated it in the data field as race does not change your treatment plan.

Pertinent negatives don't change your treatment plan either, but you must still address them.

If someone is not complaining of any pain, do I not mention anything about that since it doesn't change my treatment plan?

Edited May 31, 2011 by Dustdevil

[Lone Star]

Pertinent negatives don't change your treatment plan either, but you must still address them.

If someone is not complaining of any pain, do I not mention anything about that since it doesn't change my treatment plan?

I have to agree here. Just because I don't think that the two steel clips in my skull have anything to do with my broken ankle doesn't mean that it won't change treatment options...I'm not getting any closer to an MRI machine than I absolutely have to!

Because certain races have a higher susceptibility to certain disease processes, it's important to document the patient's race in the narrative section. Additionally, you cannot guarantee that the receiving facility staff is going to even look at the demographic and personal information fields on your PCR. Remember, your PCR is supposed to 'paint a picture' to the receiving staff. How can you give a complete image if you don't document all known information? That's like presuming that based on the current meds, the staff will automatically know the patient's past medical history....