Legal / Ethical Question....

[AnatomyChick]

I was having a discussion with a "colleague" yesterday and we disagreed on the following scenario... please read this and give me your opinion on how you think this situation should be handled.

Your on a Rural Volunteer Fire Dept, that also runs Medical calls(but does not transport). You receive a dispatch that ends up being a "full code"... you arrive at the same time or shortly after the ambulance.... you administer CPR, and provide "assisting" care (suctioning, being the IV Pole, loading the patient, etc).... The ambulance has obtained their information on the call.... Do you as a member of the Rural Volunteer Fire Dept. need to follow up with your own documentation, or can you just let it go, because the ambulance personnel on scene completed theirs. The argument is.. since this is a BLS call (somehow we're now separating running "CPR based" calls from other medical calls).. that documentation is not needed.

What do you think? I'd tell you what side I was on, but don't want to slant opinions posted.

[MedicRN]

In my opinion, you can never have too much documentation. If nothing else then to have a record to say you responded to the call (and CYA if something were to go wrong or be strategically/accidentally omitted by the other company).

However... (there's always a 'however'), if you are first on scene, a PCR needs to be completed documenting what you did for/to the patient, results of treatment, and to whom you handed care over to (and any other pertinent information) - all just as if you transported and released to the ER. Even if you arrived on scene the same time as ALS, document such..."Arrived on scene same time as XYZ ALS Company. Assisted with patient care/treatment as directed by J. Schmoe, EMT-P. Patient transported by XYZ ALS Company." If no patient contact is made by your service, document such... "No patient contact made. XYZ ALS Company on scene. PQR BLS Service released by XYZ ALS Company." Even if you ride in to the hospital as an extra set of hands, document it... simply add something to the effect of "J. Doe, EMT-B, assisted with patient care/treatment as directed by J. Schmoe, EMT-P, while enroute to ABC Hospital." You don't have to write a novel.

[Ridryder 911]

I believe one should have to have proper documentation, if you assisted or provided any care. I know our assisting agencies do not, but this has bit them as well. Since you are there as a part of the medical team, all chart and information may be pulled up in court if needed.

I do think a brief narrative such as vital signs, and some brief physical assessment should be added... especially if there is a differential in findings, complication, potential call that will be controversial or litigious . ( child abuse).More the merrier, as well, if your service is pulled in as witnesses, they have something to refer to....

R/r 911

[MedicNorth]

Document, document, document!

In our local volunteer service, which is very much like the one mentioned above, we do a PCR every time there is patient contact, regardless of the other services are there.

The most obvious reason for this is the liability issue - keeping track of what was done, what was not done, vitals, etc, can protect us if there is an issue.

Even if a PCR was not needed or done, I like to keep a brief journal entry describing the scene and actions taken. This works to jog memories if there are ever any questions or issues.

[jmac]

in my opinion, and following our guidelines, even if we do not even reach the Pt it is documented, one of the worst things in this job is communications, so if you are stood down half way there you still need to document.

All Pt's get a PCR, as you described in your scenario you made interventions, (suction, loading), though BLS you have treated the Pt even though the ambo is on scene, you can be damn sure that your interventions are stated on the ambo's PCR.

And if there is a PM for whatever case, you may be obliged to attend, is it not better to show some documentation, however little it is then to sit there trying to piece together events, documentation should always be a part of your ongoing professional development regardless of what level, better to start good habits then get caught out and embarressed.

in my opinion there are no onlookers at a scene, if you work, put it on paper then nothing comes back to bite you in the ass :wink:

[itku2er]

yes doucement by all means it might save your tail one day......I agree with JMAC always doucement every intervention .....cause if it not doucemented IT NEVER HAPPENED.......

later

Terri

[Doczilla]

Since they are 2 separate agencies, you should do your own documentation. It doesn't have to make it to the hospital, but there should be a copy filed with the rest of the PCRs for your service. This is for a number of reasons:

1) Documentation in case any actions are disputed (as mentioned)

2) Documentation in case there is any legal outcome (as mentioned). Emergency cases that go to litigation are often subject to "carpet bombing" where the plaintiff sues everyone that had their hands on the patient from the first responders on up, no matter what happened. Defendants that had nothing to do with the adverse outcome are subsequently dropped (you really can't expect to be held liable for the surgeon leaving a sponge in the patient, but you won't get dropped until the first round of depositions).

3) Call tracking, skills verification.

4) QA/QI. Medical directors, when they review run sheets, like to review the more serious calls like codes.

5) State requirements.

6) Data collection at the regional or state level.

7) Retrospective chart review for any number of reasons.

'zilla

[Shelbmedic]

In our FD the MFR's have a run report which is filled out each time they are called to a scene. This is then give to the medics on scene and then the hospital gets a copy with our run report. Means large paper trail but its a CYA thing these day.

[Dustdevil]

7) Retrospective chart review for any number of reasons.

Exactly. Without documentation, you have no way of doing QA.

If your agency is not doing QA, it sucks.

[AnatomyChick]

Our current Administration is hesitant to appoint an EMS Captain, and QA is a part of the EMS Captain's role.... I tried doing QA on this call.. which is why I noticed the lack of documentation... I brought the subject up, hence the question posted here.

Thanks for your input Dust!