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Documentation within a Patient Care Report for EMS is critical. - Dr. Robert C. Krause

Posted on 31st Mar 2020

Completing emergency medical services (EMS) patient care reports (PCRs) is a critically important component of providing quality care in the prehospital setting. The patient care report is a legal document that is used for a variety of purposes. Many organizations use the patient care report to complete internal quality assurance programs. These quality assurance programs help EMS administrators determine how well EMS crews are providing care, following their specific protocols, and how patients are being treated in the pre-hospital setting. The PCR is also a part of the admission record for a patient taken to a hospital emergency department. Medical professionals within the hospital often refer to the information contained in the patient care report written by paramedics and EMTs to better understand a patient's condition prior to their arrival in the emergency department.

Paramedics and EMTs should ensure the patient care report they are writing is complete, factual and paints a picture for the reader of the patient's condition, the treatment you provided and if the treatment you provided change the condition of your patient. For example, a patient of yours has fallen and fractured their wrist. Upon arrival of EMS the patient complains of severe pain in her wrist and feels sick to her stomach. Proper documentation would include a generalized assessment of the patient, details of how the fracture site was immobilized and if the immobilization procedures provided any pain relief and comfort for the patient. The narrative section of the PCR should include details of how the patient fell, did she become dizzy prior to the fall or did she trip over an obstruction on the floor, as an example.

Paramedics that place an advanced airway such as an endotracheal tube in the field must ensure good documentation of their actions. The PCR must include what actions were taken to ensure the endotracheal tube was properly placed into the trachea. The use of capnography in the prehospital setting is the gold standard for ensuring proper endotracheal tube placement. Some EMS organizations may include the use of a colorimetric device which changes color upon the presence of exhaled carbon dioxide. This device is used to ensure the endotracheal tube is properly placed within the trachea. The use of wave form capnography should be used as the final determinate in proper endotracheal tube placement. The American Heart Association (AHA) clearly identifies the use of waveform capnography in the management of an endotracheal tube placement. Proper documentation within the PCR needs to clearly detail your actions of what you did and what were the results of your actions. Did the patient condition improve or not?

Incomplete documentation on the part of an EMT or paramedic leavessignificant gaps in understanding of how your patient was treated. According to The Essentials of Paramedic Care (2007) on pg.745, “The narrative is the core of the documentation even if you document something in a checkbox, repeating that information in the narrative might be worthwhile, by doing so you can expand on the yes or no limitations of the checkbox to explain the timing, the assessment findings, the circumstances, or the changes in patient condition associated with the indicated action.”

EMS Professionals should also understand their writings within a PCR become a permanent record of the patient’s medical history. These medical records are often the basis for legal actions against paramedics and EMTs. Poor, incomplete or false documentation of your interactions and treatment with a patient place the EMS professional at risk of potential liability. Patient care reports are reviewed for details that include response times, serial vital signs, assessment procedures, treatment provided to the patient, how that treatment impacted the patient and finally what were the EMS protocols that guided the care provided to the patient.

EMS reports are reviewed in a manner in-which three questions could be asked.
1. What happened in this case?
2. What was expected to occur (in accordance with national & local protocols) in a
case such as this?
3. What is the difference between the two?

EMS providers must understand that documentation within the PCR needs to be complete. All actions between the EMS provider and your patient need to be written within the document narrative. As an example, specific detail documenting the need for patient restraints or of a patient's refusal of transport or the use of waveform capnograpghy must all be clearly documented. This documentation provides important insight into the circumstances surrounding your actions. Keep in mind it may be more than a year before you are questioned regarding a particular incident in which you were providing care. A well-documented PCR provides the necessary information for both the reviewer and the EMS provider being questioned.

It cannot be overstated, “what is not written down, was not done.” On many occasions when reviewing patient care reports significant gaps of information exist within the document. Upon questioning, the EMS provider indicates "oh yeah we did that, we checked that, we used that particular device,” but none of their actions were documented in the report. Unfortunately for them a long held standard of “it’s not written down, it wasn’t done” comes into play. According to Emergency Care and Transportation of the Sick and Injured (2005) pg. 81, the courts consider the following two rules of thumb regarding reports and records:
• If an action or procedure is not recorded on the written report, it was not performed.
• An incomplete or untidy report is evidence of incomplete or in expert emergency medical care.

You can avoid both of these potentially dangerous presumptions by compiling and maintaining accurate reports and records of all events and patients. Take the additional few minutes to properly and completely document each patient encounter you have. Write clearly and in as much detail as you can to fully explain what occurred during the incident. You will encounter incidents that are abnormal, challenging and difficult, take the time to write down the details of how the patient presented to you, what you did or did not do and what were the ramifications of your actions. A complete and accurate report can answer many questions and potentially prevent litigation against you and your organization years later when it is reviewed for a potential civil lawsuit.