Report Writing (Documenting Rx)

Angel

Paramedic
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I look at it like this, the more you write, the more you open yourself up to being questioned, the more questions they ask, the least likely you are to have the answers because (time and distance) and if you cant answer a question because you dont know, or dont remember is GOING to be used against you. Most anything you write will be used against you so why all the extra "fluff"? (not you just in general because I have no idea what your narratives are).

I like to stick to facts because those are what they are and there isn't really much room for conjecture or opinion.
 

Brandon O

Puzzled by facies
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"They" can ask you anything. Thorough documentation is both a defense in itself, and provides a certain defensive halo in that it implies you are a competent, thorough clinician. (So if "they" want to pin something on you, the fact that it's not in your chart is a reasonable defense, because you appear to be the sort of person who would have documented something if it had happened... and you don't seem like the sort to have done such a thing in the first place. A crummy chart makes you look like a killer.)

My rule is that within minutes after the call, I'm not going to remember anything that happened and neither will anybody else. Anything that ever comes of this, whether it's disciplinary, legal, or medical, whether it's in an hour or in ten years, will be based on what I write down. I am writing history here, probably the only version of it, so I make it good. Even if we're in a hurry or my shift was supposed to end a while ago. Again, now I'm tired, but tomorrow I won't be, and this record will remain.
 

Angel

Paramedic
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To each his own. I just think writing a dissertation makes you look equally incompetent because you can't tell what is relevant and what isn't. Same principal as throwing the ambulance at the patient because you have a poor grasp of what's going on. After all you're just "covering you bases" right ?
 

Brandon O

Puzzled by facies
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I agree that rambling like a schizophrenic is not helpful. But that's a different matter.

If by "fluff" you mean the sort of filler needed to give flow to the events, I find that helpful because I think most people want to read the narrative as a self-contained story, something that paints a picture rather than just reporting facts.

Here's another example. Again, there are other ways to do it. But I think something like this tells the reader everything they might want to know about "what happened," both quantitatively and qualititively, the sequence in which it happened, and with necessarily detail but not too much redundancy (assuming other "checkbox" recording has taken place). Read it like you're a supervisor doing QI... or a lawyer. Then imagine painting the same picture without the "filler."

Dispatched emergent to Denmark St. and Mulvaney Rd. in Waltham for an MVA.

Arrived with Waltham FD to find two vehicles in the center of the road. A small sedan has a heavily damaged back end with 2ft of compression; a midsize SUV is behind it with a broken windshield and crushed front left wheelwell. An adult male is found ambulatory, who states he was the driver of the sedan, with no apparent injury and denying any complaints. He states that he needs no care but wants his son evaluated, a teenaged male still in the front passenger seat, who also appears well and denies complaints. The father states they were struck from behind at unknown speed while stopped at a light. Both occupants endorse restraints, and there is no gross intrusion or airbag deployment. They are left in care of FD and a second unit is requested for further care.

An adult male is found in the driver’s seat of the SUV, slumped to the right against his seatbelt. He groans to painful stimulus but does not rouse. His skin is pale and cool, respirations are slow and irregular at 8/min, and radial pulse is thready and regular at 124. Breath sounds are grossly clear and equal. Oxygen is provided at 15LPM by NRB. An open abrasion is present on his left forehead, with blood found on the left upright support. There is no other obvious external trauma. A frontal airbag is deployed. There is starring of the windshield, seemingly from the airbag, and no other interior damage. ALS is requested.

The patient is manually stabilized and a C-collar is applied; he is rapidly extricated, exposed, and fully immobilized to a long spine board. He is placed on our stretcher and secured with straps x5 and rails x2, then loaded onto A104. (A11 arrives and assumes care of the other patients; see their runsheet for further.) Transport emergently to Intergalactic Trauma Center with continuing assessment en route.

Bleeding from the head wound is minor. There is diagonal bruising of the chest consistent with seatbelt trauma, and no other major bleeding or deformity. The trachea is midline and there is no appreciable JVD. Chest rise is equal bilaterally, the ribs are stable, and the abdomen is supple and without distension. Vitals note a BP of 184/100, HR 80, and increasingly shallow respirations at 6/min. A grossly dilated right pupil is also noted to develop en route. An OPA is inserted and well-tolerated. Ventilations are assisted by BVM with mild hyperventilation at a rate of 20/min.

P4 intercepts at this time and assumes dual-medic care.

[Documentation note: See PCR 121512 for full patient demographics, billing, and ALS care en route.]​
 

gotbeerz001

Forum Deputy Chief
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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.
The more you write, the more opportunities you give to accidentally contradict yourself between the narrative and the drop-down fields. Personally, if it's already been documented somewhere I may reference that area but I will not write the values twice. I need to let somebody know that the blood sugar was high I put "blood sugar low, improved post-administration of D10"… If they want to know what that specific value was, they can look back in the PCR find it.

I don't know about you, but some of the reports that I write at 3 AM may certainly have unnoticed contradictions as I am falling asleep trying to type them.
 
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COmedic17

Forum Asst. Chief
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But if I don't include something, no matter how small, in my report, they can say "well you didn't do this because if you did it should of been in your documentation."


I'm not gonna do the "he said, she said" crap in the court room. The pt could sue saying I was verbally harassing them or even assaulting him. If my report just states basic info, like " pt was secured with a 5 pt restraint in back of squad. Pt was transported to _____ with an officer in back" etc I'm going to be crucified in the court room.


If they view my report, written the day of the incident that says " pt was EPC via city police officer _____ after threatening to kill his family. Upon crew arrival pt was in police custody and handcuffs. Officer removed cuffs and assisted pt into squad. Once patient was in squad, patient refused to be secured to cot. Patient began trying to punch both medic and officer. Patient was restrained by officer while this medic secured pt with 5 point restraints. Vitals were taken to the best of this medics ability while or continued to try to fail while restrained. Vitals were ___________. Officer _____ stayed in back of squad with medic for duration of transport. Pt stated restraints were "against his rights". At one point pt stated " I am going to kill you both when I get out of these!". Pt remained aox4 with stable vitals for duration of transport to ________ hospital. Etc etc.



In one report I look like I restrained a pt, possibly without reason.
In the other report any reasonable person is going to read it and understand the situation.
 

COmedic17

Forum Asst. Chief
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The more you write, the more opportunities you give to accidentally contradict yourself between the narrative and the drop-down fields. Personally, if it's already been documented somewhere I may reference that area but I will not write the values twice. I need to let somebody know that the blood sugar was high I put "blood sugar low, improved post-administration of D10"… If they want to know what that specific value was, they can look back in the PCR find it.

I don't know about you, but some of the reports that I write at 3 AM may certainly have unnoticed contradictions as I am falling asleep trying to type them.
I'm not talking about exact vitals and such.

I just really paint the scene so someone can read it and see exactly what I saw. And I explain how, and why I sid any procedures. Instead of " a duo NRB was administered when pt said they couldn't breathe" I would say "pt began complaining of difficulty breathing. Spo2 sensor showed a reading of 96% and skin vitals where warm, pink, and dry. Pt had a respiration rate of 23. This medic listened to lung sounds which now showed mild weezes throughout, as opposed to clear lung sounds at beginning of pt contact. a duo-Neb treatment consisting of .5 mg of
ipratropium bromide And 3mg of albuterol was administered via nebulizer at 0234. Throughout treatment spo2 reading reached to 99% and pt denied any additional SOB. Weezes were no longer noted. Etc etc etc "
 

Brandon O

Puzzled by facies
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I think that's well said. Justifying your decision-making is one of the main goals here. You want the person reading to understand what happened and why you did what you did (and hopefully agree, but even if not they should at least understand without you needing to wave your hands and explain; if something needs explaining you didn't document well enough).

Imagine how you'd tell the story to another crew in the ED bay or back at the base. Clean that up and make it formal, complete, and thorough, but retain the same process. That's what I want to read.
 

COmedic17

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I have been taken to court. I did nothing wrong. But if I didn't document thoroughly, it would of been a different story. My report was so through and precise that although I had to be present at the hearing, I was never even questioned because there was nothing to question. The only thing that was asked was proof of paramedic certification. After that, I was excused because the lawyer couldn't find any loopholes in my documentation.


No one ever thinks it will happen to them. But it will.
 

gotbeerz001

Forum Deputy Chief
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I have been taken to court. I did nothing wrong. But if I didn't document thoroughly, it would of been a different story. My report was so through and precise that although I had to be present at the hearing, I was never even questioned because there was nothing to question. The only thing that was asked was proof of paramedic certification. After that, I was excused because the lawyer couldn't find any loopholes in my documentation.


No one ever thinks it will happen to them. But it will.
ImageUploadedByTapatalk1425871812.115744.jpg

Good job. [emoji482]
 

COmedic17

Forum Asst. Chief
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But I'll assume since your advocating less detailed reports that you are being sarcastic.
I'll also let you know in court my narrative was the ONLY documentation provided. Not other inserts from the report. If it wasn't in my narrative, it didn't Exist in their eyes.
So "repeating" info previously entered into the report would be a good idea.
However if you get sued it will not effect me. So be as lazy as you wish.
 

Angel

Paramedic
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307
83
But your entire pcr was subpoenaed, not just the narrative so, that's not a good reason to justify being redundant. a good "treatment as above and below" should be enough to suffice that a narrative isn't the ONLY documentation you did.
But I'll say again, to each his own.
 

COmedic17

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The prosecutor/lawyer/ whatever you want to call them can pull whatever they deem appropriate. That's what lawyers do. They only use what may help their case.

I can tell you without question my entire pcr was not there. It was soley my narrative. If my narrative was missing something I'm sure I could request/file to have the entire pcr reviewed and go through the entire court process, But at that court date- the only paperwork there to represent me was the narrative. Everything else was omitted.
 

gotbeerz001

Forum Deputy Chief
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But I'll assume since your advocating less detailed reports that you are being sarcastic.
I'll also let you know in court my narrative was the ONLY documentation provided. Not other inserts from the report. If it wasn't in my narrative, it didn't Exist in their eyes.
So "repeating" info previously entered into the report would be a good idea.
However if you get sued it will not effect me. So be as lazy as you wish.
Hahaha. Not lazy. I actually have rather thorough narratives.

Like most times on this site, you have good, passionate medics arguing with each other over the same point from slightly different angles . Lazy medics do not attempt to further their knowledge.

No one is arguing for lazy narratives. All I was saying was that pertinent info (positives and negatives) are in my narrative. I do not attempt to repeat myself but will summarize as required. If it is a non-pertinent normal finding, it is likely not in my narrative.

So seriously, good job. [emoji482]
 

akflightmedic

Forum Deputy Chief
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I agree that rambling like a schizophrenic is not helpful. But that's a different matter.

If by "fluff" you mean the sort of filler needed to give flow to the events, I find that helpful because I think most people want to read the narrative as a self-contained story, something that paints a picture rather than just reporting facts.

Here's another example. Again, there are other ways to do it. But I think something like this tells the reader everything they might want to know about "what happened," both quantitatively and qualititively, the sequence in which it happened, and with necessarily detail but not too much redundancy (assuming other "checkbox" recording has taken place). Read it like you're a supervisor doing QI... or a lawyer. Then imagine painting the same picture without the "filler."

You are being sued for delayed response time and medical malpractice (sure, its frivolous, yet happens all time)

Dispatched emergent to Denmark St. and Mulvaney Rd. in Waltham for an MVA.

What is emergent in your system? Where were you, what time of day was it? How was the weather? Did you wear your seat belt? Do you always? Did you go out the night before? Did you drink? Do you do drugs? Have you ever done drugs? When was your last EVOC/CEVO course? What have you done to keep it "current"? Were you responding from a station? Is this where you unit is normally stationed? Was the music radio on? Do you have cell phone? Do you social media? Were you texting or youtubing or anything else prior to this call? Did you text or use your phone in any way during the response to this call? MVA? Can you explain what a MVA is? Technically there are no MVAs, only MVCs.

Arrived with Waltham FD to find two vehicles in the center of the road. A small sedan has a heavily damaged back end with 2ft of compression; a midsize SUV is behind it with a broken windshield and crushed front left wheelwell. An adult male is found ambulatory, who states he was the driver of the sedan, with no apparent injury and denying any complaints. He states that he needs no care but wants his son evaluated, a teenaged male still in the front passenger seat, who also appears well and denies complaints. The father states they were struck from behind at unknown speed while stopped at a light. Both occupants endorse restraints, and there is no gross intrusion or airbag deployment. They are left in care of FD and a second unit is requested for further care.

When did you assess all of this damage? Before patient care or after? Studies show we do not remember as well as we think we do (basketball/gorilla test as evidence). Did you take pictures? Why were these not in your report? Earlier you said you did not use your phone, now you did? Are you saying the damage you saw is a result of the crash? Are you a crash expert? What is the age of the teenager, adult or minor? High speed rear impact and no "apparent injury"...did you physically assess them? Did you palpate head to toe as instructed? Did you attempt any basic exam other than just speaking to them? Do I need to remind you about mechanism of injury and "hidden injuries"? If you did these, you did not document them. If you did do these things I am gonna segue into my next line of questioning and shred you. How much time did you spend on this assessment? So you did not physically examine them but you handed care over to a "lower level of care", is this correct? (Unless the FD are Basics as well, then we drop this point and move on). So your total exam of these two is they "appear to be well", can you elaborate on that very subjective statement. If they do not need care, why did you request a second unit? Why did you not request a second unit upon arrival when noting the heavy damage and multiple patients, especially noting the fact you are a BLS unit? You state they "endorse restraints", did you visualize any marks on their thoracic cavities?

An adult male is found in the driver’s seat of the SUV, slumped to the right against his seatbelt. He groans to painful stimulus but does not rouse. His skin is pale and cool, respirations are slow and irregular at 8/min, and radial pulse is thready and regular at 124. Breath sounds are grossly clear and equal. Oxygen is provided at 15LPM by NRB. An open abrasion is present on his left forehead, with blood found on the left upright support. There is no other obvious external trauma. A frontal airbag is deployed. There is starring of the windshield, seemingly from the airbag, and no other interior damage. ALS is requested.

Is his seat belt intact? What painful stimuli method did you deploy? (hope you didn't sternal rub). Did he have any purposeful movement after the painful stimuli or did he only groan? Was his groan a result of the stimuli or just coincidence as he is actually groaning from his injuries? So he had no purposeful movement when you did this test? Was this test ever repeated? What do you mean his respiration's are irregular? Are the shallow, sighing, noisy, what? Can you define what is meant by "thready pulse"? How many seconds did you check for a pulse? Did you check a pulse anywhere else? Are you sure the starring of the windshield was not an existing issue? Are you a crash expert again? Why would you imply it is from the bag, why would you not just say windshield is starred? Do you like playing detective? I see you have CSI skills too noting the blood on the post. Can you define abrasion? How big or how small was it? Have you had an abrasion cause so much bleeding that it is transferred to another object, enough for you to notice it? Surely this was more than a simple scrape..."an abrasion".

The patient is manually stabilized and a C-collar is applied; he is rapidly extricated, exposed, and fully immobilized to a long spine board. He is placed on our stretcher and secured with straps x5 and rails x2, then loaded onto A104. (A11 arrives and assumes care of the other patients; see their runsheet for further.) Transport emergently to Intergalactic Trauma Center with continuing assessment en route.

You call this a rapid extrication? Can you please tell me what your definition of "rapid" is because at this point in time you have assessed vehicle positioning, vehicle damage, interviewed two other patients, and are now deciding to "rapidly" extricate this patient. How did you manually stabilize the patient? What size collar did you apply? How did you immobilize him to a long spine board? Did you inspect his back prior to immobilizing? What was the weather again? So you exposed the patient completely, as in removed every piece of clothing? Did you have no concern for his privacy? Are you aware youtube videos by passerbyers were uploaded within an hour of this crash? Why did you not provide a sheet and some cover? How many firefighters were on scene at this time? Are you aware of the over use and abuse of long spine boards? Do you read current medical journals within your respective field? What is an emergent transport defined as? Were lights and sirens and fast speed truly indicated or should a more smooth, expedient transport ensued? How did you properly maintain assisted ventilations while being flung all over the back of the ambulance? Who was driving? Why? Who was in back with you? Why? What is a continuous assessment and what does that entail as we already have shown you are slow in delivery of care, you do not fully examine patients and you are haphazard in maintaining their dignity?

Bleeding from the head wound is minor. There is diagonal bruising of the chest consistent with seatbelt trauma, and no other major bleeding or deformity. The trachea is midline and there is no appreciable JVD. Chest rise is equal bilaterally, the ribs are stable, and the abdomen is supple and without distension. Vitals note a BP of 184/100, HR 80, and increasingly shallow respirations at 6/min. A grossly dilated right pupil is also noted to develop en route. An OPA is inserted and well-tolerated. Ventilations are assisted by BVM with mild hyperventilation at a rate of 20/min.

The bleeding is minor? It is an abrasion right? Was there any need to control it and if so, how? In what direction was the bruising and where exactly did it start and where did it end? Did you physically palpate every extremity and check for perfusion? Has there been any color changes or improvements noted? Can you elaborate on the significance of JVD, especially as how it relates to a trauma patient or are you merely throwing out a term which sounds good? Is having JVD a good thing or a bad thing in a flat lying trauma patient? Can you demonstrate the most effective method for determining JVD? How are breath sounds? In what fields? How did the abdomen look? Did the dilated pupil just occur as you did not mention it previously? Did you even check earlier? The patient had slow and irregular respiration at a rate of 8 when you first "assessed" him, however you have waited until now to start assisting the respirations? How much time has elapsed? How is his oxygen saturation? How is his color in the finger tips, lips, any cyanosis going on?

P4 intercepts at this time and assumes dual-medic care.

How long were you on the road before the intercept? Where did you intercept?

[Documentation note: See PCR 121512 for full patient demographics, billing, and ALS care en route.]​
 

akflightmedic

Forum Deputy Chief
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Ok, ok....all the bold type is mine. I had some spare time and decided to be a douche and critically examine this. There is a point where too much information will only lead to more questions. Documenting is difficult and there is that fine line between too little and too much.

If you think a lawyer will not do his best to discredit you, even on a seemingly innocuous detail...you are wrong. His job is to baffle you with rapid fire, make you double talk, hesitate, say the wrong thing...anything and everything to prove you perceptively incompetent.

Do EMS long enough and either you or your report will be subpenaed. Thanks for playing along Brandon...even though I did not ask ahead of time. :)


I had to make TWO posts because apparently there is a 10,000 character limit per post...sheesh!
 

triemal04

Forum Deputy Chief
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Everybody really just needs to understand that documenting every single last minute detail of a call will not save you from being badgered and/or embarrassed and/or made out to have done something wrong in court.

Everybody really just needs to understand that very short reports will not save you from being badgered and/or embarrassed and/or made out to have done something wrong in court.

If someone, lawyer or not, wants to take one of your charts and use the information within to either discredit you, or to confuse you...it's very easy to do. See the above posts. And it won't matter how much or how little you write.

Write your chart so that someone reading it will understand what was going on, what you did, and why you did it. Because...you know...that's the point. There is a point where people just need to accept that only so much can be done for protection.
 

Brandon O

Puzzled by facies
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Do EMS long enough and either you or your report will be subpenaed. Thanks for playing along Brandon...even though I did not ask ahead of time. :)

:D Strong work.

I'm sure some of this was just taking the piss, but the majority of your points fall under two categories:

1. Details documented elsewhere. The idea behind the narrative (or at least the style I prefer) is to tell the story in an understandable way, with the details that make it understandable. Exhaustive lists of facts are invariably found elsewhere in the ePCR systems I've used.

2. Applicable either way. I'm not sure if this is the point you're arguing against or something you'd agree with, but somebody can question your care no matter what. I don't think documenting less information avoids this; the question can still be asked, and indeed more of them. But if you documented things at the time -- something that's clearly defensible as the standard of care -- you have much more of a leg to stand on than an explanation fabricated de novo ten years later after the lawsuit.

The one exception, I suppose, is if you don't know what you're doing and document something plainly wrong or foolish. In that case you're better off keeping your lip zipped. But if you know your stuff and document that stuff, it's a strong support for you. (In other words, all of your questions are thoroughly answerable, something I hope we can posit without actually going through them... but it could be done in court. Or with a really vulturish CQI guy.)
 
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