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 Elements of a well-written report should include: Content: provides as much information as needed to give the reader a clear picture of what happened. This includes pertinent negatives such as “pt. denies cp or chest discomfort”. Accurate: contains specific details relevant to the incident. Objective: details specific facts that in general are not disputed. Almost entirely comprised of findings from physical exam.

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? 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 Duty: Legally recognized responsibility to always perform how a reasonable, prudent, and properly trained person of your position would perform under the same or similar circumstances. Breach of Duty: Failure or departure from the standard of care. Standard of Care: Exercising the degree of care, skill, and judgment, which would be expected under the same or similar circumstances, by a similarly trained, reasonable, and prudent pre-hospital provider. Scope of Practice: Duties and skills allowed to practiced through certification and training. Generally will follow accepted protocols and medical control. Negligence: Abandonment: Causation: If it can be proven that the provider breached his/her duty to the patient, the patient must then prove that the breach of duty was the actual cause of the injuries or damages suffered. Damages: Economic (loss of job, lost wages, attorney’s fees, medical costs). Physical (loss of function). Pain and suffering for a physical injury. Must be proven in court.

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

Over 80% of EMS lawsuits are not directly related to patient care. 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. Vehicle accidents are the major liability issue for fire/EMS. With most accidents occurring enroute to the scene, primarily at intersections. Creates potential for both criminal and civil liability issues. Also includes “getting lost” either through bad dispatch information or crew unfamiliarity with service area. Abandonment is define as the improper termination of patient care or turning the patient over to someone who is not qualified to provide care for the patient. Dropping Patients: not having enough manpower for the job or equipment failure. Equipment problems include “dead defibrillators”, empty oxygen cylinders, and inoperable EMS equipment. Patient Care Issues: Airway Management (intubation), Improper extrication, failure to provide spinal immobilization, medication issues such as over dosage, wrong medication, or outdated meds.

Documentation Problems 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 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 RCW 44.17.310 RCW 70.02.150 All documents created by government RCW are available for review with 2 exceptions: RCW 44.17.310 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 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” Documentation is the foundation in ay major event (lawsuit) and your substituted memory.

Remember! If you did not write it, it did not happen! Memory is fallible, claims may not be filed until years after an event. Use correct spelling, be factual, accuracy counts, objective format, and be as complete/thorough as possible. Mechanics are important. Documentation is the KEY to an affirmative legal defense.

You are hereby summoned ..… 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 This is your best protection against legal problems that could arise

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 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 Subjective information usually comes from the patient, family members, or caregivers

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 Objective findings are specific facts that, in general, cannot be disputed. Objective findings include: level of consciousness, patient positioning, head to toe exam findings, lung sounds, and vital signs every 5 minutes. ECG tracing/12 lead tracings, SPO2/ETCO2 readings, and BGL measurements when appropriate.

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

See MIRF for incident detail See MIRF for incident detail. Each student will record info and develop SOAP narrative on handout. Review by section (Subjective, Objective, Assessment, Plan) in class by having selected students read their written narratives.