Personal documentation

What personal documentation do you keep after a call?

  • I'll document it if it was a "bad" call

    Votes: 0 0.0%
  • That's what EMS forms are for

    Votes: 0 0.0%
  • I've got the memory of an elephant

    Votes: 0 0.0%
  • I'll have forgotten it before I leave the ER

    Votes: 0 0.0%

  • Total voters
    1

SafetyPro2

Forum Safety Officer
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Got to thinking about this while responding to another post.

Do you keep personal documentation of the calls you go on? I'm not talking about copies of run reports or anything like that, but a rather something like a log. I personally keep a running log of every call we get dispatched for, primarily in case I ever get subpoenaed or if there were ever to be a complaint made.

Personally, I've got a spreadsheet set up and copy the dispatch info from my text pager into it. I also track in there whether or not I responded (and whether or not I ended up at the scene or just at the station) and, if appropriate, what apparatus I was assigned to and/or what role I played. For medical calls, I make a brief note of the patient's condition when found and what actions I personally took. If it's something like a full arrest, I generally put in a bit more info. One thing I do NOT document is personal info (name, SSN, etc.). I also don't generally document others' actions...just the actions I took.
 

Chimpie

Site Administrator
Community Leader
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It appears my response is not listed above so...

In my last position I documented just the specifics: date, time, location, type of run and run/report number. If anything really weird happened I'd jot that down as well but that was rare.

Chimp
 

rescuecpt

Community Leader Emeritus
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At the ambulance corps when we return to the house the dispatcher takes the PCR, enters the times, who what when where etc into a fancy computer system, and the PCR gets filed away for posterity. You can then search by your name for a list of all the calls you've been on. As long as your name is on the PCR, you will have a computer printout of what calls you've been on, who else was there, what the patient complaint was, the times and date, and what hospital you went to.

Beyond that, don't worry, if you're ever called to court, they give you the PCR to study before you testify. Just make sure that you document everything on your PCR - if it's not there, it didn't happen!

The FD is less advanced, we have the radio log, the call log, and the PCRs filed away for posterity.

Unfortunately, I dont really have the time, nor desire, to keep track of all of the calls I've been on. It's like scuba diving - at first I logged all my dives - once I passed 1,000 I lost interest, and once I certified over 150 students I stopped keeping track of them too - the dive shop has that all on file for me.
 

ResTech

Forum Asst. Chief
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I never saw a personal need to keep any personal records of call details. All relevent call info is stored electronically and on paper at the station. Pennsylvania has electronic data collection so all PCR's are completed via computer.
 

ffemt8978

Forum Vice-Principal
Community Leader
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Given that we never see our PCR's again until we go to court, I keep a running database of every call that I have patient care on. I don't enter any of the patient info that would even be close to HIPAA protected, but I do enter the run number and PCR number, so that it can be traced back to the call.

I tend to keep the narrative fairly similar to my PCR, but will add things that I don't feel comfortable putting on the PCR.

My department keeps an unofficial log book for every call, and they require us to write in it. I don't, because I feel any records kept by the department are subject to being subpeonaed, and it would be impossible to produce just the one entry for the court. That would lead to every one of our calls being looked at by a good attorney, and some of the comments in the book would get us in trouble. The department says that the attorneys would have to request the book entry specifically, but the last time I looked a subpeona usually had a statement like "and all relevant records, documents, and reports". If my unofficial record got subpeonaed, I could print out the relevant report and keep the rest of the database out of court.
 
OP
SafetyPro2

SafetyPro2

Forum Safety Officer
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The way I see it, the run form covers the overall treatment, and while it does document who did what (such as O2, vitals, etc.), it would be hard for me to go back and read one after two years and be able to say what exactly I personally did. Plus, my name may be on the report as a responder, but I may not have actually done much, so I can look at my notes and say "All I did was strap him on the gurney."

Non-medical calls, however, have even less documentation. Our incident reports will tell what happened and what actions were taken as a whole, but don't record who, for example, was on a hoseline or who was up on the roof. Just lists the officers and the FF on the ambulance and utility.

My Captain told me he was once subpoenaed for a call (not a medical, BTW) and had no recollection of the call at all. In court, they produced the record that showed his name, and it was the roster that showed he'd responded to the station, but not the scene, so he could honestly say he didn't do anything. Woulda been different had he been on-scene though.
 

MMiz

I put the M in EMTLife
Community Leader
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I don't keep any sort of log for EMS calls. I understand your reasons for keeping them, but what if they are used against you in the future? I was watching a news show today on MDs being sued for over-documentation. I just got home from work and wasn't in the mood to watch, it was a rough day, but it was an interesting concept.
 
OP
SafetyPro2

SafetyPro2

Forum Safety Officer
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Originally posted by MMiz@Jul 23 2004, 09:03 PM
I don't keep any sort of log for EMS calls. I understand your reasons for keeping them, but what if they are used against you in the future? I was watching a news show today on MDs being sued for over-documentation.
The way I look at it, I only document information I'd be asked to provide in court anyway. I think it's a lot better to be able to say "I did X" rather than "I don't remember what I did."
 

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