Leadership

DOCUMENTING THE “QUIET” CONVERSATION

Issue 8 and Volume 159.

BY MICHAEL P. DALLESSANDRO When I took my first paramedic training program, the instructor, who was also my seventh grade English teacher, offered us some words of wisdom regarding his views about documentation of patient care. “If you don’t write it down, it didn’t happen,” he said. What he meant was that if you performed CPR on a dying patient and made your best effort to save that person’s life but failed to note the CPR on the patient-care form, a lawyer representing that person’s family may contend you did not perform CPR at all, and disputing this contention could prove difficult. Another way to put this training mantra, which also happened to be the slogan of a local printing company, was “Verbal orders don’t cut it; write it down.” The key point is that documentation is vital in any matter that may become contentious down the road. It is…

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