# Report Writing (Documenting Rx)



## JefferyLebowski (Mar 5, 2015)

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


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## Flying (Mar 5, 2015)

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.


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## planetmike (Mar 5, 2015)

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.


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## Flying (Mar 5, 2015)

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


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## JefferyLebowski (Mar 5, 2015)

Flying said:


> 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.


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## NomadicMedic (Mar 5, 2015)

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.


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## JefferyLebowski (Mar 5, 2015)

DEmedic said:


> 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.


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## RebelAngel (Mar 5, 2015)

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.


]


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## RebelAngel (Mar 5, 2015)

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/


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## Carlos Danger (Mar 5, 2015)

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.


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## DesertMedic66 (Mar 5, 2015)

Remi said:


> 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.


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## Carlos Danger (Mar 6, 2015)

DesertEMT66 said:


> 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".


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## ERDoc (Mar 6, 2015)

Remi said:


> 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



Remi said:


> 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.
> 
> ...



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.


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## Jason (Mar 6, 2015)

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.


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## Angel (Mar 7, 2015)

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.


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## DesertMedic66 (Mar 7, 2015)

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.


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## NomadicMedic (Mar 7, 2015)

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.


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## Brandon O (Mar 8, 2015)

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.​


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## COmedic17 (Mar 8, 2015)

Flying said:


> 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.


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## COmedic17 (Mar 8, 2015)

Angel said:


> 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.


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## Angel (Mar 8, 2015)

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.


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## Brandon O (Mar 8, 2015)

"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.


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## Angel (Mar 8, 2015)

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 ?


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## Brandon O (Mar 8, 2015)

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.]​


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## gotbeerz001 (Mar 8, 2015)

COmedic17 said:


> 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 (Mar 8, 2015)

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.


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## COmedic17 (Mar 8, 2015)

gotshirtz001 said:


> 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 "


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## Brandon O (Mar 8, 2015)

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.


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## COmedic17 (Mar 8, 2015)

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.


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## gotbeerz001 (Mar 8, 2015)

COmedic17 said:


> 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.








Good job.


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## COmedic17 (Mar 9, 2015)

gotshirtz001 said:


> View attachment 1899
> 
> Good job.


I have difficulty differentiating sarcasm over the Internet.


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## COmedic17 (Mar 9, 2015)

gotshirtz001 said:


> View attachment 1899
> 
> Good job.


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.


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## Angel (Mar 9, 2015)

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.


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## COmedic17 (Mar 9, 2015)

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.


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## Angel (Mar 9, 2015)

Okay


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## gotbeerz001 (Mar 9, 2015)

COmedic17 said:


> 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.


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## akflightmedic (Mar 9, 2015)

Brandon O said:


> 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.
> 
> ...


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## akflightmedic (Mar 9, 2015)

*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!*


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## triemal04 (Mar 9, 2015)

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.


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## Brandon O (Mar 9, 2015)

akflightmedic said:


> *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. *



 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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## BecomingaBetterEMT (Mar 9, 2015)

I use saying keep it simple stupid, KISS. Obviously anything out of the ordinary a would make not of but really saying that you secure the pt with straps is unnesscary.


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## RefriedEMT (Mar 10, 2015)

I still use what I learned in the class and my first ems company. SOAP Subjective, Objective, Assessment, Plan and I write my report in that order. Essentially just write what the PT and bystanders told you, what you saw and did, a few possibilities that need to be ruled out such as CHF in a chest PX call and then I just write every intervention that I performed (plan) during the call such as administering O2 with NC or NRB. So pretty much just what the guy above me said, keep it simple. You would not believe how simple some EMTs i've seen write their reports, it made me think it was always extremely quick and easy but you just gotta work at it and you get faster and faster writing these reports. I started out taking more than 10mins to write a full report, after a while I could get one done in 4-5mins, the city will force you to get better and faster because I can still remember my FTO telling me we had 911 calls waiting in our area and freaked out and wrote like a damn tornado.


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## Akulahawk (Mar 10, 2015)

I have used a few different methods of writing my narrative... mostly I used a variation of SOAPIE. I don't do a ROS as  you'd find in an H&P so that makes things a bit shorter to write. While I don't double chart certain things, I will reference data that is listed elsewhere if it's pertinent. My assessment is basically my field diagnosis and is therefore what I'm basing my treatment plan on. I usually then list my interventions actually done and then evaluate the response to those interventions and repeat the cycle.

Usually then I'll end the report with a disposition of the patient and who I turned the patient over to. 

Done right, writing this only takes a few minutes. The downside of this method is that you _might_ chart too much detail leaving the pertinent stuff (pos and neg) in the weeds. It's also very easy to double chart stuff using this method and while that's not a bad thing, it takes up space you might use for something else, and you could chart the same item differently which could call your entire report into question. After all, if you goofed on one thing, perhaps you goofed on other stuff...


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## Carlos Danger (Mar 10, 2015)

Excellent post, @akflightmedic


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