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Posted

Amazingly excellent article.

Plus it validates my long winded, short on abbreviations style of PCR writing, so there's that...

Everyone should read it.

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Posted

My lead instructor is a Attorney and frequent paramedic expert witness in court cases. He not only recommends this article but drills us constantly about not skipping or abbreviating anything in the PCR's. He states that they "simply will not pass muster in court". He also recommends to use the patients own words as much as possible because if we ever end up in court it will be years after the call was run and we will probably have forgotten most of the details that the plaintiff will have shared with his/her legal counsel.

Posted

There should be in every EMS system a list of accepted abbreviations and if your system does not have one they better get one. You are asking for problems and legal issues if you don't have a list.

HOspitals have them for just that reasons.

Posted

Luckily, our ePCR software will only allow you to use the acceptable state abbreviations. I prefer people write things out, and use simple terms.

You have a patient at an MVA. You're using AMBU Brand single size collars, which we don't, but I'm being general. One of the sizes is "No Neck", others say Neckless. The collar that best fits me, is "neckless".

If you write, placed c-collar on patient. That's great, or placed neckless collar, tall collar, etc.

But I've seen people write "placed no neck collar on patient".

To me, that says placed size "no-neck" collar. To the general public, or a lawyer that wants to burn your ass, that says "I didn't put a collar on".

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Posted

There should be in every EMS system a list of accepted abbreviations and if your system does not have one they better get one. You are asking for problems and legal issues if you don't have a list.

HOspitals have them for just that reasons.

Abbreviation list may help with local reporting but; What if you end up in court out of state or by a lawyer that wants to make issue with abbreviations and their different significance in different places?

What if your local list is different from the list of abbreviations that the lawyer downloaded from the internet? I think plain English,although more tedious in reporting will "abbreviate" legal difficulties should they arise.

Posted

Abbreviation list may help with local reporting but; What if you end up in court out of state or by a lawyer that wants to make issue with abbreviations and their different significance in different places?

What if your local list is different from the list of abbreviations that the lawyer downloaded from the internet? I think plain English,although more tedious in reporting will "abbreviate" legal difficulties should they arise.

IF you are called into court from a patient that you took care of at the hospital then the hospital lawyers will have that list of abbreviations and can submit that into evidence.

If you are on your own and have your own attorney then you can tell your attorney(if you can think that proactively) that the abbreviations you used were taken from the list of approved abbreviations at the hospital you used to work at.

If you are on your own totally, then you just say that you used the old employers list of approved abbreviations

BUT and I STRESS this, I always used full words, not abbreviations. It may take more work to write Epinephrine or Milligrams out but with my handwriting trust me, it's much better to do that if I'm handwriting a report.

The computerized reports are a different story. The room for error in a typed narrative is significant if you are using abbreviations.

I attended a lecture by a local attorney who said not to use abbreviations in a computerized report format and he gave some examples but I"m drawing a blank right now what those examples were.

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