Transcript DOCUMENTATION - LSU Fire and Emergency Training Institute

DOCUMENTATION
The Patient Care
Report, avoiding
liability and winning
lawsuits
The Paramedic & EMT legal duties
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To the patient
To the employer
To the Medical Director
To the Public
LEGAL DUTIES DEFINED
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Statutes and Regulations
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Based on accepted Standards of Medical Care
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2000 AHA ECC Guidelines
Lee County Medical Protocols
Florida Department of Health-Bureau of Emergency
Medical Services
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Chapter 64-E, Florida Administrative Code
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Licensing, Certification, Permitting
Medical Direction
Records & Reports
Pre-hospital Requirements
ETHICAL RESPONSIBILITIES
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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
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Failing to perform EMS duties appropriately
can result in civil or criminal liability
LIABILITY
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The best legal protection is providing
appropriate assessment and care coupled with
accurate & complete documentation
LAWSUITS
LAWSUITS
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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
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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
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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
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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
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Legal
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CYA
State requirements
Q/A
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Educational
Review for need to change
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Procedures
Equipment
SOGS
RATIONALE FOR DOCUMENTATION
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Statistics
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Justify budgets
Justify personnel
Justify needs
Awareness of problem areas
Others
CURRENT LEGAL CLIMATE
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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
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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
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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
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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
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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
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SOP-procedures that require mandatory
compliance
SOG-the requirement is a goal to be achieved
under the best of circumstances
SOP’S / SOG’S
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If you decide to deviate from protocol assure:
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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
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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
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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
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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
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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
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Before you are challenged, make sure that
your reports are…….
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Right
Complete
Persuasive
They are your voice long before you get a
chance to speak
DOCUMENTATION
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If you saw it,heart it, smelled it or thought it……
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THINK! If your instincts tell you that the item is
probably important, then it probably is……….
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WRITE IT DOWN!
WRITE IT DOWN!
Tell what you sensed, why you felt it was
important, what you did in reaction and why
DOCUMENTATION
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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
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Use- “There was a strong alcohol-type odor”
Use- “He slurred his words”
10-COMMANDMENTS OF
DOCUMENTATION
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RULE 1
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IF YOU SENSED IT, WRITE IT
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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
10-COMMANDMENTS OF
DOCUMENTATION
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RULE 2
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WRITE IT IN A TIMELY FASHION
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As soon as practical
In the courts, a record that is not timely is less trustworthy
due to fading of memory over time
10-COMMANDMENTS OF
DOCUMENTATION
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RULE 3
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BE NEAT AND LEGIBLE
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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
10-COMMANDMENTS OF
DOCUMENTATION
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RULE 4
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BE COMPLETE
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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?
10-COMMANDMENTS OF
DOCUMENTATION
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RULE 5
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BE SPECIFIC
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Use quotes when applicable
But, make sure it makes sense
10-COMMANDMENTS OF
DOCUMENTATION
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RULE 6
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SUPPLEMENT
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Additions to reports in order to add information originally
omitted is not only acceptable but reasonable
State the reason for the original omission
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Error
– Did not seem relevant at the time
– Not known and came to light later
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Should be dated and time stamped
Do no cover up that it is supplementary
10-COMMANDMENTS OF
DOCUMENTATION
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RULE 7
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AUTHENTICATE AND PUBLISH
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Initial and date all changes or additions to original reports
with notice to all who may have received a copy.
10-COMMANDMENTS OF
DOCUMENTATION
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RULE 8
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DO NOT ERASE PRIOR DATA
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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
10-COMMANDMENTS OF
DOCUMENTATION
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RULE 9
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USE UNDERSTANDABLE TERMS
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It is acceptable to use words and phrases commonly used
in the profession
Avoid abbreviations when possible
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If using, use standard abbreviations
10-COMMANDMENTS OF
DOCUMENTATION
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RULE 10
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READ WHAT YOU WROTE
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If there is the shadow of a doubt as to whether it is clear,
revise it now
READ WHAT YOU WROTE!
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“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!
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“Gators To face Seminoles With Peters Out “
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(The Tallahassee Bugle)
“Alzheimer’s Center Prepares For An Affair To
Remember”
“Gas Cloud Clear Out Taco Bell
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(Miami Herald)
YOUR STATE OF MIND
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May determine the report’s quality
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Complacency
Fatigue
Burn-out
Sour attitude
Poor work habits
YOUR STATE OF MIND
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The one that burns you may be……
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The routine drunk
The “frequent flyer”
The nursing home call
Signal 4 in the rain, etc.
FIRST RESPONDERS
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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
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Audio tapes are becoming as critical as the run
report itself
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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
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Chief Complaint
History of present illness/injury
Physical exam
Past medical history
Current meds
Allergies
Treatment
BASICS OF A RUN REPORT
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Chief Complaint
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Primary problem or complaint
Use patients own words only if applicable
BASICS OF A RUN REPORT
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History of present illness/injury
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Onset of symptoms
Provocation
Quality of pain or discomfort
Radiation?
Time symptoms began
Associated symptoms
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Other signs present
Associated factors
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Mechanism of injury, speed, objects, etc.
BASICS OF A RUN REPORT
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Physical exam
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Head to toe survey
BASICS OF A RUN REPORT
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Past medical history
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Patient’s pertinent medical history
BASICS OF A RUN REPORT
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Current meds
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Any pertinent meds
Document if meds given to LCEMS
BASICS OF A RUN REPORT
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Allergies
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Meds
Latex
Tapes
BASICS OF A RUN REPORT
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Treatment
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All treatment rendered to the patient
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Include times in sequential order
Note changes
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Improve
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Number of times attempted to tube or start IV and at what
point it became successful or not
BASICS OF A RUN REPORT
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SAMPLE
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Symptoms
Allergies
Medications
Past medical history
Last oral intake
Event leading to injury or illness
BASICS OF A RUN REPORT
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OPQRST
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Onset
Provocations
Quality
Region or Radiations
Severity
Time
BASICS OF A RUN REPORT
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DCAPBTLS
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Deformities
Contusions
Abrasions
Punctures
Burns
Tenderness
Lacerations
swelling
BASICS OF A RUN REPORT
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Make it complete
Make it honest
Make it simple
Review it
Be Professional
QUIZ FOR PROFESSIONALS
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The following quiz tells weather you are
qualified as a professional or not.
QUIZ FOR PROFESSIONALS
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How do you put a giraffe into a refrigerator?
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Open the refrigerator, put in the giraffe and close the
door.
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This questions tests weather you tend to do simple things
in an overly complicated way.
QUIZ FOR PROFESSIONALS
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How do you put an elephant into a refrigerator?
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Open the refrigerator, take out the giraffe, put in the
elephant and close the door.
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This tests your ability to think through the repercussions of
your actions.
QUIZ FOR PROFESSIONALS
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The Lion King is hosting an animal conference.
All the animals attend except one. Which
animal does not attend?
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The elephant. The elephant is in the refrigerator.
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This tests memory.
QUIZ FOR PROFESSIONALS
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There is a river you must cross, but crocodiles
inhabit it. How do you manage it?
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You swim across. All the crocodiles are attending
the animal conference.
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This tests weather you learn quickly from your mistakes.
QUIZ FOR PROFESSIONALS
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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.