Think, Then Write!

     When I arrived at work, I wondered why Ted's truck wasn't parked behind the station, since it was only about five minutes until shift trade.

     I threw my gear on the rig, and noticed that Ted's gear wasn't hanging on the other side. I knew for a fact that he was scheduled to work the shift, but when I saw Rich Gladwell, another paramedic, in the kitchen, I knew something was up. He clarified everything quickly with a couple-of-sentences tale of woe. Rich was held over on a call-back/overtime from last shift because Ted had apparently seen fit to write, "This lady is a dim bulb" on a patient care report. In return, our shift commander made sure there was a written reprimand in his file, and the chief decided to add insult to injury by suspending Ted for a day without pay. Pretty stiff price to pay for some poorly thought out prose, to say the least.

     For whatever reason, preparing a patient care report periodically attempts to bring out that repressed fiction or fantasy writer, or the comedian who lurks somewhere in every EMSer's psyche. While I agree the temptation is mighty, there are, at a minimum, at least three good reasons to ignore that little voice in your head that encourages you to "add a little spice" to your patient care report.

It's Unprofessional
     Making any type of value judgment or derogatory statement about a patient on a legal document, as my former partner unfortunately chose to do, can be described in many ways. Some words that leap to mind are: unacceptable, inappropriate and stupid. In the end, they all paint the same picture of the unprofessional. Whether referring to someone's home, clothes, kids or whatever, value judgments or derogatory statements have no place whatsoever on a patient care report.

     Just the fact that someone is thinking the kinds of thoughts that lead to writing these statements about other human beings in the first place lends itself to questioning what type of care those folks are actually providing. When providers devalue people in their thoughts and writing, it's foolish to think it won't or doesn't impact their patient care, because it does. That's no way to go about being a professional EMSer, as I understand it.

You Impact the Medical Record
     For the sake of discussion, let's say you document level of consciousness as "the patient wasn't quite with it." Having now assumed the care of your patient, the ED staff are trying to develop their patient care game plan, and when they check to see what the patient's baseline neuro status was in the field, they find your pithy, but useless, comment about the patient's mentation. By now, you are long gone and on your way to the next call, so there's no way for the doctor or one of the nurses to ask you in person, leaving them no choice but to wonder how the patient initially presented in the field and hoping that it doesn't impact the overall morbidity or mortality of the patient's outcome.

     As another example, let's say the patient who complained of being short of breath gets documented on the patient care report as being a "wheezing geezer." Because of that, reimbursement for the ambulance call is denied, and the patient and his family get to play the paperwork shuffle to get reimbursed for what truly was an ALS call, all because you were a poet who decided to show it.

Medico-legal Compromise
     Another area where inappropriate documentation can have a huge impact is in the legal arena. In this scenario, your document states that the driver of the car that crossed the center median was "as drunk as a skunk." While it may seem funny at the time, when you are deposed by the plaintiff's attorney, believe me, it won't be funny. "How drunk do skunks get? Have you ever actually seen a drunk skunk? When a skunk decides to get drunk, what would be the drink of choice?" All you had to write was, "The patient behaved as if he was intoxicated," and you wouldn't be sitting in the hot seat talking about drunk skunks.

     In the worst-case scenario, what happens if your frivolous documentation either contributes to or is the primary cause of the case being lost, and another drunk driver is returned to the highways, thanks to you? Explain that to the next family he destroys.

     Once you have made the decision about what to document in a run report, recognize that you stand at the edge of a permanent moment. Whether you are hand-writing the report or using a software program, once you submit the document, your words are memorialized forever.

     Ask yourself the following: Is what I've written appropriate and professional? Have I accurately documented the patient's presentation and care events in a way that will provide solid information to the ED staff? Will what I've written and documented create reimbursement problems or compromise some legal event?

     If any of the information contained in any patient care report doesn't answer one of the questions above, it's probably best to consider removing it prior to turning the report into a historical document.

     Now, where was that drunk skunk?

     Until next month...

Mike Smith, BS, MICP, is program chair for the Emergency Medical Services program at Tacoma Community College in Tacoma, WA, and a member of EMS Magazine's editorial advisory board.