BY MIKE McEVOY
Medical documentation enjoys incredible benefits that other professions can only dream of. If you wrote a note after wrecking the family auto that said, “I was driving cautiously, following all vehicle and traffic laws, when a green pickup truck crashed into the side of my car,” you’d probably be greeted with a good deal of laughter. Yet, every EMS run provides you with the opportunity to write a similar note and have it admissible in court to boot. It doesn’t get much better than this. But, exactly what should you write? People overly wrapped up in documentation might advise, “Write everything.” The phrase “If you didn’t write it, you didn’t do it” represents an extreme of the “write everything” documentation approach. In practice, nothing could be further from the truth.
THE PATIENT CARE REPORT
The purposes of medical documentation are to convey your findings and treatment to other caregivers and payors and to serve as a tool for assessment of your professional conduct. Medical records are like any other writing: Examples of both good and bad documentation abound. Good documentation fulfills the purpose for which it is intended. A well-written patient care report (PCR) forms a picture in the reader’s mind of what happened and in what chronological order. A good PCR is factual and has a professional appearance. A bad PCR lacks substance, is often poorly written, and tends to convey an unprofessional image of the writer. Poor documentation fails to take advantage of the full range of benefits medical documentation could provide.
When interviewing a patient, bystander, or family member, you filter information, honing in on the pertinent details, discarding extraneous information. Pertinent information can be positive, such as loss of consciousness, seizure activity, or use of a seat belt. It could also be negative information such as no loss of consciousness, no chest pain, no difficulty breathing, and so on. The same technique applies to medical documentation: You should filter your notes to include only information pertinent to the situation. Be mindful that your report is written to transfer information to other providers and payors and to document your professional conduct. These affect what is pertinent. A PCR the length of a novel is not likely to be a good medical record; brevity is an important attribute of excellent medical records.
For your PCR to paint a picture of a typical EMS response, you’ll need to reflect the who, what, where, when, and why elements of the run.
• Who. At a minimum, identify who called you, who the patient was, who was on the scene, who treated the patient, and who transported the patient.
• What. Include what you found on arrival-a brief description of the scene, patient position, care in progress by others on your arrival, and details useful for someone reading your report to form a mental image of the incident.
• Where. This should include where you encountered the patient and where the incident occurred.
• When. This portion of the report reflects the event timeline and is often crucial in reconstructing a response. From the perspective of definitive medical care, timelines can be critical, especially when treatments are provided or withheld based on time of symptom onset. Timelines frequently help or hurt medical legal case evaluations-the most defensible reports tend to be those that clearly show the chronological order of events. Since your report will serve as your memory of a patient encounter and human memory works chronologically, it makes good sense to write and review your reports for the accuracy of their timeline. Be sure that treatment and assessment times correlate with dispatch, response, arrival, and transport times.
• Why. Your rationale for why you did certain things and why you didn’t do certain things is notable. Don’t be afraid to put your thoughts on paper: It serves to connect the dots between your assessment and treatment. When you have a good reason for not doing something, make a note of it. For example, noting that an IV was not started because the patient refused or that atropine was not administered for a heart rate of 48 because the patient was asymptomatic will prevent others down the line from second guessing your care.
THE CASE FOR BREVITY
Brevity is a hallmark of good medical documentation, and three items give you good reason to not record every miniscule detail: protocol, standard practice, and common sense.
Protocols guide EMS at virtually every practice level. State, regional, local, and department protocols are sometimes so detailed that they specify exactly what and how patient care should be provided. When protocols call for elaborate or precise actions, why not reference them directly in your documentation? The medical and nursing professions do this routinely. A typical nursing note might include statements such as “Dressing changed per Central Venous Line Protocol” or “Patient extubated per protocol without complications.” Obviously, if you reference protocols by writing, for example, “18 French orogastric tube placed per protocol,” you’d better know the protocol.
Standard practice provides a similar opportunity to keep your documentation concise. In fact, it would be difficult to find a surgical operative report that didn’t use the phrase, “in standard fashion” at least once or twice. Like heart surgery, many procedures we perform in the field have a standard way of being done with which virtually any provider or textbook would agree. There is no sense in documenting obvious details such as which hand you held the laryngoscope with or secured an IV with tape. Pertinent information begins where the obvious ends. Consider details such as whether the cords were visualized, how much air was injected into the ET tube cuff, and where the tube was secured at the lips as pertinent to an intubation. Details that are not obvious convey important information and reveal much about the writer’s professional knowledge.
Common sense, although probably not so common, includes details that even an untrained layperson would intuitively understand. For example, treatment requires consent, yet we do not routinely document obtaining consent. Likewise, common sense tells you that a provider treating an open fracture would wear gloves, a fact rarely mentioned in documentation. Common sense tells us that a patient pulled from a bathtub or swimming pool would be wet; failure to note that fact does not make the patient dry.
Medical documentation conveys a picture of what you saw and did in the field so that others can properly care for your patient. It also serves to show that you acted properly and professionally. To effectively accomplish these goals, you need to write a clear and concise report that includes details pertinent to the patient and your response. Plenty of what you do is guided by protocol, standard practice, and common sense. Record the details that aren’t obvious, and for unmistakable particulars, keep in mind that “not written, not done” is just not so. ■
■ MIKE McEVOY, PhD, REMT-P, RN, CCRN, is the EMS coordinator for Saratoga County, New York; chief medical officer for the West Crescent Fire Department; and EMS director for the New York State Association of Fire Chiefs. He is a clinical coordinator and instructor in cardiothoracic surgery at Albany Medical College in New York and a member of the editorial advisory boards for Fire Engineering and fire/EMS.