Transcript NSCC Report Writing

Report Writing
A RGT Presentation
Elements of a Good Report
• Content: Clear picture of what happened,
includes relevant facts as well as pertinent
negatives.
• Accurate: Specific details related to call
• Objective: Based upon YOUR findings
• Factual: No assumptions or conclusions.
• Complete: Are all of the boxes checked?
• Timely: Same day completion
A Complete Report
Timely
Concise
Makes every word count
Concrete fact with descriptive detail
Clarity
Uses accepted abbreviations
Short sentences or phrases
Why Written Reports?
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Compilation of statistical data/research
Legal documentation (EMS/Fire)
Record Keeping Regulations
Justify budget requests, code enforcement,
resource allocation
• Prepare court cases with relevant facts
• Coordinate FD activities
• Evaluate individual/department performance
Report Writing
and the
Law
Legal Definitions
Duty
Breach of Duty
Standard of Care
Scope of Practice
Negligence
Abandonment
Causation
Damages
Most Litigated Issues in
Fire/EMS
Termination Issues
Hiring Issues
Medical Malpractice
Sexual/Nonsexual harassment
Civil Rights Violations
Whistle Blower Retaliation
Management Relations with Volunteers
Vehicle Accidents
EMS Liability
Vehicle Accidents
Abandonment
Dropping Patients
Equipment Problems
Patient Care Issues
Confidentiality
Over 80% of EMS lawsuits are not directly related to
patient care.
Documentation Problems
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Deficiencies
Discrepancies
Omissions
Treatments & Patient Responses
Unapproved abbreviations
Errors of Omission or Commission
– Undocumented information
– Incorrect or erroneous information
Modifying Reports
Misconception – “we cannot touch the chart
after it is completed.”
Reality is that late entries and corrections are
permissible
– Should be appropriately noted and dated
– Addendums allowed if dated and initialed
– Corrections should be made by the original
author
Modifying Reports
• Errors may be corrected with a single
strikeout line, initialed and dated by the
original author – NO white out!
• Supplemental narrative sheets are also
permissible if more space for the narrative
or if the call had an unusual presentation
Supplemental Narratives
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Homicides/suicides
Rescues
Domestic violence, child or elder abuse
Rape or sexual assault
Violent acts towards EMS providers
Potential for lawsuit (AOB pts.)
“Weird” stuff
Remember:
Keep a copy of your
supplemental report for your
records
Public Disclosure
• RCW 42.17.260
– All documents created by government RCW are
available for review with 2 exceptions:
• RCW 44.17.310
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Personnel records/Employment applications
Social Security Numbers
Intelligence reports
Witness Identification
• RCW 70.02.150
– Medical records
Confidentiality
• Personnel Records
• Fire Investigative Reports
– Cause
– Evidence
– Contacts
• EMS Reports
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EMS/Provider confidentiality
Patient history
Assessment findings & treatment
Criminal activity involved?
Confidentiality Violation
Invasion of privacy
Defamation
Slander
Libel
The improper release of information or the release of
inaccurate information can result in liability
Release of Information
Requires written permission from the patient or their
legal guardian
Permission is not required for the release of select
information
– That provides others with the “need to know” to
provide medical care
– When required by law
– When required by a third party for billing
– In response to a proper subpoena
So,Think You Are Protected?
• Statute of Limitations
• RCW 4.24.300 Good Samaritan Laws
– Are you covered off duty?
• RCW 18.71.210 EMS Immunity Act
– Generally protected for acts of omission
• RCW 4.96.010
– Sovereign Immunity Waived
– Local government liable for tortuous actions
Your Best Defense?
• Take the appropriate course of action – think
accountability, proper documentation
• Follow medical direction – off & on line
• Provide accurate and thorough documentation
• Always maintain a professional attitude and
demeanor
• Maintain education, training, and continuing
education
• Think in the long term
Accountability
• Use specific formats and standards
• Incorporate legally defensible writing
strategies
• Protocol templates (SOG’s, directives)
• Jurisdictional EMS policies
– Federal, State, County, Departmental
– Standard of Care, Scope of Practice
Documentation
• Legally relevant information
• In compliance with the established Standard of
Care
• Double check your writings
• How you choose to document may come back to
haunt you later.
• This is your “real time” memory
• Created in the “course of business” and not in
“anticipation of litigation”
Remember!
If you did not write it,
it did not happen!
You are hereby summoned ..…
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First, and foremost, don’t panic!
Contact your supervisor
Contact your agency’s legal representative
Gather up all documentation that you may have to
help refresh your memory.
• “No comment” is a useful tool to use in any
litigation.
• Remember, most issues are settled before they go
to trial.
Effective Report Writing
Some ideas
A Well Written Report
Should be:
Concise
Clear and well organized
Mechanically correct
Written in standard English
Legible
Completed on time
Written in ink
5 Steps in Writing Reports
• Gather facts: observe, investigate, and
interview
• Record facts immediately, take notes!
• Organize the facts
• Write the report
• Evaluate the report: edit/proofread, revise if
necessary
Effective Reports
• Completed Promptly
– Record is made “in the course of business”, not
long after the event
– Not in “anticipation of litigation”
– Prompt recollection essential as it becomes part
of a permanent record
Effective Reports
• Completed Thoroughly
– Adequate coverage of assessment, treatment and
relative facts when dealing with patient care
– Should paint a clear, complete picture of what
transpired, events leading to and actions after an
incident.
– Should enable another to have a good idea of what
happened even though they were not there.
Effective Reports
• Completed Objectively
– Observations rather than assumptions or
conclusions
– Avoid the use of emotionally and value loaded
words or phrases
– Based upon your physical findings
– Legally relevant, in compliance with
established standards of care
Effective Reports
• Completed Accurately
– Descriptions should be as precise as possible
– Avoid using non-standard abbreviations or
jargon not commonly understood
– If you are not sure how to write it – write it in
English
– And YES, spelling does count.
Effective Reports
• Maintain confidentiality
– Each agency has a policy on the release of
information
– Whenever possible, consent should be obtained
prior to the release of information
– Copy becomes part of the permanent record
– Statues of limitations is 3 years unless capital
offense
Medical Incident Report Forms
Some more ideas
Medical Incident Report Form
• Documents the events
of an EMS response
from beginning to end.
• Becomes a part of the
patient‘s permanent
medical record.
• It is also a legal
document.
EMS Reports
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Pt. name, age, chief complaint
Medical History
Medications/Allergies
Physical Assessment
Treatment and response to treatment
Transfer of care
Remember to use Patient Refusal Form
Flow Chart
• Supplements the written narrative
• Provides brief overview of patient status
throughout your care
• Documents times for specific therapies and
events
• Should complement the written portion of
narrative.
SOAP Format
• Subjective:
– What the patient tells you (reason for the call)
Chief complaint, NOI/MOI
– Patient’s past history
– Risk factors for other pathologies
– Pertinent negatives
– Physical sights, sounds, smells
– Document patient verbatim
SOAP Format
• Objective:
– Physical findings from exam
– Vital signs, breath sounds
– Orderly process, neck/head to toe or body
systems approach
– Not opinion, only factual findings
– Don’t’ forget: SpO2, BGL, EKG tracings
SOAP Format
• Assessment:
– Your best guess of the patient’s problem based upon
your subjective and objective findings
– What you believe the problem is and justifies your
treatment plan
– Not expected to make a diagnosis – rule out only
– If issue is obvious, then document as such
SOAP Format
• Plan:
– Specific treatments and actions taken
– Remember to record patient’s responses to treatment
– Remember: exam, assessment and treatment must “add
up”
– Document medical control contact
– Patient refusal of treatment
– ALS evaluation of BLS patients