documentation the patient care report, avoiding liability and winning lawsuits

DOCUMENTATION

The Patient Care Report, avoiding liability and winning lawsuits

The Paramedic & EMT legal duties

To the patient To the employer To the Medical Director To the Public

LEGAL DUTIES DEFINED

Statutes and Regulations– Based on accepted Standards of Medical Care

2000 AHA ECC Guidelines Lee County Medical Protocols

Florida Department of Health-Bureau of Emergency Medical Services

– Chapter 64-E, Florida Administrative Code Licensing, Certification, Permitting Medical Direction Records & Reports Pre-hospital Requirements

ETHICAL RESPONSIBILITIES

Responding with RESPECT to the physical and emotional needs of every patient

Maintaining mastery of skills Participating in continuing ed/refresher training Critically reviewing performance and seeking

improvement Reporting honestly Working cooperatively & with respect for other

emergency workers and health care professionals

LIABILITY

Failing to perform EMS duties appropriately can result in civil or criminal liability

LIABILITY

The best legal protection is providing appropriate assessment and care coupled with accurate & complete documentation

LAWSUITS

LAWSUITS

A vehicle stalls on a bridge and its occupants leave to obtain help. Their empty vehicle is struck in the rear by another vehicle. They get back inside before the police arrive. They claim injury from the collision

LAWSUITS

A wedding guest at a reception sues his dancing partner for causing his ankle injury, even though a video tape shows the “victim” dancing through the evening without a problem.

LAWSUITS

An intoxicated driver traveling over 75 miles per hour causes a multi-vehicle accident. He sues the driver of every other vehicle involved. He also sues responding police, fire and medical personnel for negligent treatment of his injuries.

LAWSUITS

An increasing number of suits are in fact without merit and even fraudulent.

It is therefore important to be in a position at all times to counter even the unexpected.

The key is PROPER DOCUMENTATION

LAWSUITS

RATIONALE FOR DOCUMENTATION

Legal– CYA– State requirements

Q/A– Educational– Review for need to change

Procedures Equipment SOGS

RATIONALE FOR DOCUMENTATION

Statistics– Justify budgets– Justify personnel– Justify needs– Awareness of problem areas

Others

CURRENT LEGAL CLIMATE

Most emergency responders believe there is little chance of being sued

Lawsuits for negligence are few in comparison to the the number of agencies in the country

What the stats do not show are the numerous incidents of internal disciplinary hearings, claims and lawsuits filed that result in unrecorded disciplinary action or monetary settlement

CURRENT LEGAL CLIMATE

Just being called in as a witness can be embarrassing and degrading

Your intelligence, integrity, character and competence may be challenged throughout the process

PROACTIVE APPROACH

Most negligence suits against emergency responders that are successful, either by way of settlement or verdict, are the result of a lack of preventive maintenance

PROACTIVE APPROACH

One critical area is that of creating standards for report writing

An injury victim’s attorney will request by letter or subpoena, administrative records, run reports or medical narratives.

PROACTIVE APPROACH

A poorly written report may fail to document that the responder followed proper treatment and response protocols

This may result in the responder and/or his agency becoming potential defendants

All documents should be written in the knowledge that they may be analyzed for potential negligence

SOP’S / SOG’S

SOP-procedures that require mandatory compliance

SOG-the requirement is a goal to be achieved under the best of circumstances

SOP’S / SOG’S

If you decide to deviate from protocol assure:– That SOP has already been followed and they have

not worked– Something other than SOP’s must be done– You have contacted an “up-line expert” and

informed him that operating procedures were followed, that they failed, and that he wishes to make a deviation

– You receive specific permission to proceed and has documented the entire communication in your run report

DOCUMENTATION

You know exactly what happened You know why you did it If you have to tell your story to those that

question you, you will be vindicated

DOCUMENTATION

You won’t be asked to give your version until someone else has already complained and given their version

Whatever you say will be “in response” to someone else’s version and will and will be suspect since you have a self-serving motive

DOCUMENTATION

What you must do is to protect yourself each and every day in each and every incident that has the potential for trouble by telling your story in a form that the law will recognize as highly believable and persuasive

Written documentation is not the best way to get your story across………..

IT’S THE ONLY WAY!!

DOCUMENTATION

It is not just important to document thoroughly, it is often LEGALLY CRITICAL!

In virtually every controversial situation, before you get the opportunity to relate the story, the complainant has been heard, the records have been checked and often, minds have been made up as to who was wrong and who was right.

DOCUMENTATION

Before you are challenged, make sure that your reports are…….– Right– Complete– Persuasive

They are your voice long before you get a chance to speak

DOCUMENTATION

If you saw it,heart it, smelled it or thought it……– WRITE IT DOWN!

THINK! If your instincts tell you that the item is probably important, then it probably is……….– WRITE IT DOWN!

Tell what you sensed, why you felt it was important, what you did in reaction and why

DOCUMENTATION

Stay away from conclusions and opinions Stay as factual as possible Do not report that people were “drunk”. Do not use words like “wreaked” of alcohol

– Use- “There was a strong alcohol-type odor”– Use- “He slurred his words”

10-COMMANDMENTS OF DOCUMENTATION

RULE 1– IF YOU SENSED IT, WRITE IT

If you saw it, touched it, smelled it or heard it, it should be recorded.

Be specific If instincts tell you it is relevant or important, it probably is


RULE 2– WRITE IT IN A TIMELY FASHION

As soon as practical In the courts, a record that is not timely is less trustworthy

due to fading of memory over time


RULE 3– BE NEAT AND LEGIBLE

It’s appearance, it’s legibility, it’s ability to be easily understood is a reflection on the person who prepares it

Neat, legible writing carries more weight If the report is not typed, print Use black ink for durability and legibility Proper spelling helps integrity

NEAT & LEGIBLE


RULE 4– BE COMPLETE

The reader should be able to view and feel the scene as you saw and experienced it.

What was the time constraint? What was the urgency?


RULE 5– BE SPECIFIC

Use quotes when applicable But, make sure it makes sense


RULE 6– SUPPLEMENT

Additions to reports in order to add information originally omitted is not only acceptable but reasonable

State the reason for the original omission– Error– Did not seem relevant at the time– Not known and came to light later

Should be dated and time stamped Do no cover up that it is supplementary


RULE 7– AUTHENTICATE AND PUBLISH

Initial and date all changes or additions to original reports with notice to all who may have received a copy.


RULE 8– DO NOT ERASE PRIOR DATA

If a change is made to an original, it should be clear what was changed

White-out should NOT be used If a word is being changed, there should be a single line

through it, and the correction should be made next to it The change should be initialed and dated


RULE 9– USE UNDERSTANDABLE TERMS

It is acceptable to use words and phrases commonly used in the profession

Avoid abbreviations when possible– If using, use standard abbreviations


RULE 10– READ WHAT YOU WROTE

If there is the shadow of a doubt as to whether it is clear, revise it now

READ WHAT YOU WROTE!

“Patient has chest pain if she lies on her left side for over a year”

“She has had no rigor or shaking chills, but her husband states he was very hot in bed last night”

“The patient has no past history of suicides” “The skin was moist and dry”

READ WHAT YOU WROTE!

“Gators To face Seminoles With Peters Out “– (The Tallahassee Bugle)

“Alzheimer’s Center Prepares For An Affair To Remember”

“Gas Cloud Clear Out Taco Bell– (Miami Herald)

YOUR STATE OF MIND

May determine the report’s quality– Complacency– Fatigue– Burn-out– Sour attitude– Poor work habits

YOUR STATE OF MIND

The one that burns you may be……– The routine drunk– The “frequent flyer”– The nursing home call– Signal 4 in the rain, etc.

FIRST RESPONDERS

Record any treatment given by anyone who initially rendered care, improper or not

You must identify them, if possible and their level of expertise

AUDIO TAPES

Audio tapes are becoming as critical as the run report itself– Reflect what actually happened– Reflect the attitude of the speaker

Sarcastic tones, tones indicating anger, complacency or indifference that are played in front of a judge or jury can damage your credibility

BASICS OF A RUN REPORT

Chief Complaint History of present illness/injury Physical exam Past medical history Current meds Allergies Treatment


Chief Complaint– Primary problem or complaint– Use patients own words only if applicable


History of present illness/injury– Onset of symptoms– Provocation– Quality of pain or discomfort– Radiation?– Time symptoms began– Associated symptoms

Other signs present

– Associated factors Mechanism of injury, speed, objects, etc.


Physical exam– Head to toe survey


Past medical history– Patient’s pertinent medical history


Current meds– Any pertinent meds– Document if meds given to LCEMS


Allergies– Meds – Latex– Tapes


Treatment– All treatment rendered to the patient

Include times in sequential order Note changes

– Improve– Worse– Same

Number of times attempted to tube or start IV and at what point it became successful or not


SAMPLE– Symptoms– Allergies– Medications– Past medical history– Last oral intake– Event leading to injury or illness


OPQRST– Onset– Provocations– Quality– Region or Radiations– Severity– Time


DCAPBTLS– Deformities– Contusions– Abrasions– Punctures– Burns– Tenderness– Lacerations– swelling


Make it complete Make it honest Make it simple Review it Be Professional

QUIZ FOR PROFESSIONALS

The following quiz tells weather you are qualified as a professional or not.


How do you put a giraffe into a refrigerator?– Open the refrigerator, put in the giraffe and close

the door. This questions tests weather you tend to do simple things

in an overly complicated way.


How do you put an elephant into a refrigerator?– Open the refrigerator, take out the giraffe, put in the

elephant and close the door. This tests your ability to think through the repercussions of

your actions.


The Lion King is hosting an animal conference. All the animals attend except one. Which animal does not attend?– The elephant. The elephant is in the refrigerator.

This tests memory.


There is a river you must cross, but crocodiles inhabit it. How do you manage it?– You swim across. All the crocodiles are attending

the animal conference. This tests weather you learn quickly from your mistakes.


According to Andersen Consulting Worldwide, around 90% of the professionals they tested got all questions wrong.

Many preschoolers got several correct answers.

This conclusively proves the theory that most professionals have less brains than that of a four year old.

documentation the patient care report, avoiding liability and winning lawsuits

Documents

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process slide

collision slide

proper documentation

criminal liability slide

monetary settlement

winning lawsuits

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