Report Writing (Documenting Rx)

[JefferyLebowski]

Hi all,

I'm very green. I got my basic license in December of last year, and I got hired part time at a midsized EMS company a few weeks ago. I'm finishing up school, so I've been picking up different shifts with different EMTs, each of whom have been showing me the ropes in their own ways. Its been pretty dizzying.

My company uses CHART, and now that I'm actually working, I wish school had covered that more thoroughly. Anyways, one EMT told me that I should make a point of writing down everything I did when it comes to patient care. "Helped pt from bed to stretcher, secured x2 straps, etc." Another told me to just write, "palliative care," even correcting me when I started to go back to the first method. Recently, I ran again with the first EMT, and she told me the other guy is lazy, and that I should write it out.

I'll write it out if I have, but now I'm confused, especially since all the PCRs I wrote since that night had "palliative care" written for Rx whenever I just sat in the back, finishing my report. Is it going to get me in trouble? Does it depend on the organization? I'm afraid to go ask people in my company, as it's small enough that they will most certainly know who I'm talking about.

Thanks. I hope I posted this in the right place

 

[Flying]

You will not go wrong by adding more detail. If you start the chart, make it your own and don't let anyone else mess with it too much.
You probably won't get in trouble since you just started, but if you're in doubt about charting things in a certain way, then it's probably not the way to go.

Also take the knowledge you take from your peers with a bit of salt.

 

[planetmike]

I am still struggling with report writing as well. Basically, document what you need to document so that when you’re hauled into court in five years, you’ll be able to explain what you did to and for the patient and why. You will not remember the patient, so the only thing you’ll have to go on is the written record. I do like the D-CHART format, although some of my preceptors don’t. It’s probably better to over-document than under-document.

 

[Flying]

Also, what does Rx stand for? I'm assuming it isn't referring to medications. Report? Treatment?

 

[JefferyLebowski]

Also, what does Rx stand for? I'm assuming it isn't referring to medications. Report? Treatment?

Treatment, yeah. I think the medics can use that slot if they push meds, as well.

 

[NomadicMedic]

I make it a habit to write what I did. If I helped the patient stand and walk 5 steps to the stretcher and then secured them with straps, I write that. If the patient ran out of the house and jumped into the ambulance as it came to a stop, I write that too. You should detail as much as you can. I will tell you, if you're ever sitting at a conference room table, in a deposition, an attorney will chew you up for "palliative care". It means nothing. Write what you did.

 

[JefferyLebowski]

I make it a habit to write what I did. If I helped the patient stand and walk 5 steps to the stretcher and then secured them with straps, I write that. If the patient ran out of the house and jumped into the ambulance as it came to a stop, I write that too. You should detail as much as you can. I will tell you, if you're ever sitting at a conference room table, in a deposition, an attorney will chew you up for "palliative care". It means nothing. Write what you did.

Thanks, that's what I needed to hear.

 

[RebelAngel]

Look at it this way, if it were to go to court, and the only thing you were able to bring into court for your own benefit was that PCR, what would you have wished you would have written down?

"Palliative care" doesn't cover what you did or how you did it and that could come back to bite you in the butt. It also doesn't show that you know what you're doing or they what you're doing is helping or did help the patient. What it boils down to is if you don't write it down you can't prove you did it if it were to go to court or a QI meeting.


I don't know how it is for you, but in my state the state has a list of what has to be on a PCR, bare minimum. "Palliative care" just wouldn't cut it in my state. (See below, esp. points I highlighted)

The documentation included on the PCR provides vital medical information and must be true and accurate. The PCR must include, but not be limited to: • Date of call, • Agency name, code number and responding vehicle information • Call Location and “Geo” Code, • Dispatch information, call location and call times • Type of call: Emergency/Non-Emergency/Stand-by, • Hospital or other disposition and the disposition code, • Patient Name and address • Patient Date of Birth and Gender • Presenting problem, • Chief Complaint as described by the patient or family/bystanders • At least two complete sets of vital signs • Subjective Assessment as described by the patient or family/bystanders • A written narrative detailing: • the objective physical assessment • past and current medical history • All treatment provided by the EMS agency’s personnel • Crew names, level of certification and NYS certification number.

]

 

[RebelAngel]

Write down pertinent negatives too. IE "Patient denies chest pain", "Patient denies falling", "Patient denies having diarrhea"...and on and on

Here's a thread about pertinent negatives:
http://emtlife.com/threads/pertinent-negative.33063/

 

[Carlos Danger]

I disagree that writing more is always better.

Pertinent information should be charted, of course. But impertinent detail (the number of steps to the stretcher?) is simply clutter and does nothing to help form a cogent patient record, with billing, or with legal defensibility.

We are always threatened with "well, if you are hauled into court 5 years from now, you'll WISH you'd charted every tiny detail", but what gets you in trouble is poor patient care and poor documentation of your patient care, not failing to include details that have no bearing on the clinical course.

 

[DesertMedic66]

I disagree that writing more is always better.

Pertinent information should be charted, of course. But impertinent detail (the number of steps to the stretcher?) is simply clutter and does nothing to help form a cogent patient record, with billing, or with legal defensibility.

We are always threatened with "well, if you are hauled into court 5 years from now, you'll WISH you'd charted every tiny detail", but what gets you in trouble is poor patient care and poor documentation of your patient care, not failing to include details that have no bearing on the clinical course.

I see some value in documenting the steps to the gurney for some patients. If you walked a SOB patient to the gurney it can make a huge difference if it was 2 steps or 50 steps. I'd more than likely get pulled in by CES if they read I made a SOB patient walk a marathon to the gurney.

 

[Carlos Danger]

I see some value in documenting the steps to the gurney for some patients. If you walked a SOB patient to the gurney it can make a huge difference if it was 2 steps or 50 steps. I'd more than likely get pulled in by CES if they read I made a SOB patient walk a marathon to the gurney.

This comes back to documenting only pertinent findings or actions; only things that are clinically relevant or have other potential implications (privacy, important patient satisfaction elements) for the patient or yourself.

We don't document that we "deferred complete exposure and a detailed head-to-toe physical exam" when the patient is a 17 year old female whose only complaint is that she smashed her fingers in a car door. You don't chart that because of course you wouldn't completely undress a 17 year old female whose only complaint is a minor, isolated distal extremity injury. You would never do that, so the fact that you didn't doesn't need to be charted. Similarly, you would never make a patient with severe SOB walk a long distance to the gurney. It doesn't have to be stated because no one would do that to a sick patient.

Now, if you did for some reason choose to completely expose the 17 year old female whose only complaint is a minor extremity injury, then that is pertinent precisely because it is very unusual, and also because it clearly has potential implications. Therefore, the reason you did it needs to be thoroughly documented and justified. Similarly, if you did make a patient with severe SOB walk a long distance for some reason, that needs to be documented because it could have clinical implications and is therefore relevant.

It simply isn't true that the more you write, the safer you are. Writing lots of detail is actually potentially hazardous, because when you do try to document every little thing that did or didn't happen, you throw away the potential protection (the assumption that you performed routine tasks normally and documented everything that was important) that comes with charting by exception. The more detail you write, the easier it is to miss something. And if you are going to take the approach that you chart everything, that is when it becomes true that "if you didn't chart it, it didn't happen".

 

[ERDoc]

I disagree that writing more is always better.

Pertinent information should be charted, of course. But impertinent detail (the number of steps to the stretcher?) is simply clutter and does nothing to help form a cogent patient record, with billing, or with legal defensibility.

We are always threatened with "well, if you are hauled into court 5 years from now, you'll WISH you'd charted every tiny detail", but what gets you in trouble is poor patient care and poor documentation of your patient care, not failing to include details that have no bearing on the clinical course.

This

This comes back to documenting only pertinent findings or actions; only things that are clinically relevant or have other potential implications (privacy, important patient satisfaction elements) for the patient or yourself.

We don't document that we "deferred complete exposure and a detailed head-to-toe physical exam" when the patient is a 17 year old female whose only complaint is that she smashed her fingers in a car door. You don't chart that because of course you wouldn't completely undress a 17 year old female whose only complaint is a minor, isolated distal extremity injury. You would never do that, so the fact that you didn't doesn't need to be charted. Similarly, you would never make a patient with severe SOB walk a long distance to the gurney. It doesn't have to be stated because no one would do that to a sick patient.

Now, if you did for some reason choose to completely expose the 17 year old female whose only complaint is a minor extremity injury, then that is pertinent precisely because it is very unusual, and also because it clearly has potential implications. Therefore, the reason you did it needs to be thoroughly documented and justified. Similarly, if you did make a patient with severe SOB walk a long distance for some reason, that needs to be documented because it could have clinical implications and is therefore relevant.

It simply isn't true that the more you write, the safer you are. Writing lots of detail is actually potentially hazardous, because when you do try to document every little thing that did or didn't happen, you throw away the potential protection (the assumption that you performed routine tasks normally and documented everything that was important) that comes with charting by exception. The more detail you write, the easier it is to miss something. And if you are going to take the approach that you chart everything, that is when it becomes true that "if you didn't chart it, it didn't happen".

And this

The purpose of the chart/documentation is to provide anyone caring for the pt after you information about what the pt told you and what was done for the pt. Simply writing "palliative care" is useless to those coming after you. It is often helpful to us in the hospital to know what was done in the field. As the physician, I don't always have a chance to talk with EMS about what was done so I refer to their chart. As many may or may not have heard, the whole observation versus inpatient debacle makes admitting pts difficult sometimes. Sometime you provide a treatment in the field that makes their numbers look better and because of that they will only meet observation status. If you have documented a number that would allow the pt to meet inpatient status, that helps us help the pt. It also allows us to see how your treatment has affected the pt.

I won't pretend to know how EMS billing works anymore but if it is anything like hospital billing, your billing, your company's existence and your livelihood depend on good documentation. Insurers are looking for reasons not to pay the bills anymore. You (not referring to anyone specific, just a general 'you') may not think billing is a big deal, but when your company shuts down because of possible fraud or because they can't pay you any more, it becomes a big deal.

I don't think palliative care means what your partner thinks it means.

As others have said, your documentation is often the only thing that you have to go on when it gets called to court. It often takes years before you even get notified that there is a pending lawsuit. I can tell you from experience, it is always the one that you never thought would sue who is the one that will sue. It will be one of those routine pts that you will not be able to recall because they all blend into one. Saying, "I can't remember," is not going to work as a defense. Good documentation is what will shut down lawsuits, but there is such thing as too much also.

 

[Jason]

Our agency uses electronic charting, like most places I would imagine. We also have a narrative format that we are expected to follow. Even when generating our narrative, and filling in what is needed - we use A.C.H.A.R.T.D.(E.)
I've been taught and have tried to practice, to include all findings, both positive and negative, and all treatments given and refused. Paint a picture when documenting.

 

[Angel]

Writing too much can get you in trouble as well. Tbh the likely hood of being sued doing ift stuff is low, but as stated, palliative care doesn't mean much. I usually would wrote monitored o2, vs and whatever else you need to monitor. Include a secondary assessment, if any changes and that's about it. Write it so someone from the outside looking in knows what's going on.

 

[DesertMedic66]

The hard part for us is that we only have one narrative section in our PCRs. So we need to provide appropriate info in it for the hospital staff, our county CES/Data collection, Company CES, and billing department.

Does it make a difference to the ED if I put in "patient was secured to the gurney using all approved seat belts"? Not in the slightest. Can we get pulled into the supervisors office if our PCR gets pulled for review? Yes.

 

[NomadicMedic]

PW&W offered a great documentation class, taught from an EMS attorney's point of view. Well worth it, if it's offered neat you.

You'll learn that writing to much can get you jammed up, but not writing enough of the important stuff is worse.

 

[Brandon O]

Narratives in general are a balance between actually providing useful documentation for anybody who might want it, and covering your butt. Bad examples are purely the latter with none of the former. Really bad ones do neither.

Here's an example of how I used to do routine transfers. This doesn't work for everybody, and in particular is more than many people want to write, but take what you will from it.

Dispatched non-emergent to Waldorf Memorial Hospital (6 West) for discharge to Mumford Rehab.

Arrived on floor and met by staff, who provide paperwork/signature/report. Patient is Mr. Jeeves, a 73 yo male with hx of COPD and CHF, who presented with chest pain and dyspnea. He was found negative on cardiac enzymes with nonspecific ECG changes, admitted for further monitoring, and eventually underwent cardiac catheterization with no acute occlusions found. He is now stable and is being discharged to short-term rehab for gait training.

He is found in bed, alert and semi-Fowler’s, fully oriented with some general confusion, and denying acute complaints. There is some peripheral pallor, and non-pitting edema of the lower extremities. Vitals unremarkable, as noted above [note: in our ePCR, the vitals screen prints out above the narrative]. A locked IV is present in his left forearm.

He is transferred to our stretcher, secured with straps x5 and rails x2, and loaded onto A56. Transport routinely with monitoring en route. No changes in status during transport.

Arrived without incident, offloaded, and brought Mr. Jeeves to his room. He is transferred into bed and left in a low position, rails up, with his call button and belongings. His care and paperwork are transferred to staff.​

 

[COmedic17]

Also, what does Rx stand for? I'm assuming it isn't referring to medications. Report? Treatment?

I have always used / seen Rx as medication/prescriptions, Tx as treatment, and Hx as past medical history.

 

[COmedic17]

Writing too much can get you in trouble as well. Tbh the likely hood of being sued doing ift stuff is low, but as stated, palliative care doesn't mean much. I usually would wrote monitored o2, vs and whatever else you need to monitor. Include a secondary assessment, if any changes and that's about it. Write it so someone from the outside looking in knows what's going on.

Why would someone get in trouble for writing too much?
Not arguing, just curious.


I have always considered my report MY report and it's going to be what saves My butt if I ever go to court, and it's a direct reflection on my patient care....so I put whatever I please in it. Which is typically a lot more then what most people would, but at the end of the day- that's a direct representation of me. If I ever do go to court I know the other lawyer is going to try to find any holes they can. It's not just for billing. It's a personal safety net.