Five Simple Ways to Improve Your Documentation Skills

As we have preached so many times in the past, good documentation is important to you and your ambulance service for many reasons. Good documentation can facilitate good patient care, help protect you from liability and can favorably impact your ambulance service’s reimbursement.

This EMS Law “Monthly Tip of the Week” presents five quick and easy things you can do to improve your documentation right now!

1. Paint a Picture
   Think of your documentation as painting a picture of the incident. However, instead of using a paintbrush or a camera, you are using words. Set the scene. For instance, at an accident scene — Where are the cars? Is there broken glass and tire marks? Is there significant damage to the vehicles and was the passenger compartment compromised? What are sights, sounds and smells are registering on your senses?
2. Use Chronological Narratives
   Avoid the tendency that some EMS providers have to jump around as things enter their minds. Stay focused; write your narrative so it flows in chronological order and that the steps of your dispatch, assessment, treatment and transport are documented in a logical fashion. This can be especially problematic when too much time passes between the call and the time the documentation is done. Document when the call is as fresh in your mind as possible.
3. Stick to the Facts
   A well-written patient care report is objective instead of subjective. This means that your charts should stick to the facts, and leave out the personal interpretations and “spin.” For instance, don’t say your patient simply was “intoxicated.” Instead, document the facts that lead you to that conclusion, such as “patient’s speech was slurred”; “odor of alcohol on patient’s breath;” “patient admitted drinking 8 beers in the past hour” and other such objective facts.
4. Abandon Home-Grown Abbreviations
   Many EMS providers love to use home-grown abbreviations. Reading their charts is like grading a test and they’re the only ones who have the answer key! Abbreviations are fine, but stick to ones that are common and accepted in the health care professions. Your service can even consider adopting a standard table of abbreviations to be used in your company’s patient care reports.
5. Spelling Counts
   Finally, we know that this is a tough one, and not everyone has top-notch spelling skills, but proper spelling and grammar is important. Remember, if a jury looks at your chart someday, and your chart is full of errors, it may lead a jury to conclude you are as sloppy at patient care as you are at documentation. Nobody’s perfect in this department, and medical terminology can be especially tricky to spell properly. So, pick up an EMT textbook or get a medical dictionary at the station and commit to learning a new word or two on each shift. It helps your vocabulary – both in EMS and in life – and improves your trip sheets to boot.

   For other EMS Monthly Tips of the Week, visit http://www.pwwemslaw.com/ACTIVE/Tips/TipArchivesDefaultPage.htm.

   Courtesy of Page, Wolfberg & Wirth, LLC.