Patient viewing your documentation

[Dustdevil]

I am fairly liberal in allowing patients access to their records. I freely allow my patients to view or have copies of their records at any time, once they are completed, reviewed, and signed. The only formality is that they sign a standard release of records first. Of course, this is for a clinical practice, and not ambulance EMS. However, were I administrating an ambulance EMS service, my policy would be much the same, subject to review by my legal advisors.

[AnthonyM83]

Anthony, that situation you were in was a precarious one.

Fortunately for you nothing has come of her questions of you and her in the back of the ambulance but if something did come out of it and she accused you then you would be the one having to prove your innocence as everyone in the media would have gotten wind of it and they would have had a field day.

I can just see it now.

Headline Anthonyville "Veteran Ambulance Driver accused of (insert your own story here)"

ONce that accusation is out then you and any provider out there are screwed with a foot thick pole. There is no way to clean up your name after that has been accused. Even if you were completely totally and utterly innocent you will always be seen or considered the one who did the unthinkable. It totally sucks.

One accusation and an otherwise stellar career is down the crapper.

I'm glad it didn't come to that.

Best thing is to document the heck out of those types of dirtbags. Those types of people make me sick.

Let's be safe out there people.

Yup.

I documented the heck out of that call on a separate incident report form stating explaining how she was encouraging patients on-scene to go to the hospital, quotes from her in the back of the ambulance of her asking if I was always alone with patients in the back, if my patients in the back were unconscious sometimes (I told her in those cases the back's usually crowded with additional medics), and if I liked being the one with the patients versus driving. Also, how she was talking about suing the bus company while we transferred her to her hospital bed, and aggressive comments made to staff. I also gave a heads up to the charge nurse. Documented what I did and said in response when she made the awkward comments.

I was hesitant to even write it at first, because a copy would go in my personnel file and I'd rather any topic close to that not be associated with my file, but I just explained how the report was voluntary and written to protect myself and the company from someone who seemed unstable to me and already talking about suing the bus company. I also added a more thorough medical history than the medics on-scene had gotten, including her partial psych hx and psych meds.

But it's still disturbing how easily one's name could potentially be tarnished and how quickly your ambulance company would drop you. If anything, it was practice as good documentation in case a more serious situation did come up.

[Just Plain Ruff]

This discussion leads me to one of my book recommendations.

The book is called The Missing Protocol

It is a wonderful book about how to write a legally defensible ambulance report.

this book does not teach you how to write a report, it already assumes you know how to do that. But what it does do is go through and help you understand that some of what we write is rife with the possibility of nailing us to the wall in court.

If you read this book I guarantee you will be a better report writer, one who looks outside the box and will say, wow I didn't even realize it could go that way.

I highly highly recommend this book.

[AnthonyM83]

Wow, Amazon's charging $149 for it...

[Just Plain Ruff]

actually the bookseller listed is a really high priced bookseller. they think most of their books they sell are golden.

It's been a while since I priced it.

Ok it seems that the book has now been made into a 8 hour class. The book is no longer in print but it's on CD

Here is a link to the site.

https://www.themissingprotocol.com/site/edu...nal_program.htm

The guy selling the book for 149.00 is an idiot. He says it's a very rare book.

[CBEMT]

actually the bookseller listed is a really high priced bookseller. they think most of their books they sell are golden.

It's been a while since I priced it.

Ok it seems that the book has now been made into a 8 hour class. The book is no longer in print but it's on CD

Here is a link to the site.

https://www.themissingprotocol.com/site/edu...nal_program.htm

The guy selling the book for 149.00 is an idiot. He says it's a very rare book.

I tried ordering the book through that website almost a year ago. Never heard from them.

[Doczilla]

Anthony's situation brings up another good point- any interference by the patient in their own care, interference by family members, threats to sue or other statements of dissatisfaction should be documented in the medical record. Be as specific as possible; quoting the patient as saying, "paramedics are sadists that like to hurt people" is better than saying "the patient makes irrational statements about prehospital personnel" (of course, if talking about Dustdevil, this isn't that irrational). Rather than saying "pt is uncooperative", cite the uncooperative behavior (pt. refuses to hold still for BP readings, pt refuses to answer medical questions and instead screams obscenities at me, pt somnolent and will not follow commands). If a patient clearly wants a certain treatment that you feel is not indicated or you are unable to provide, document this as well.

'zilla