1. Report Writing
A RGT Presentation

2. 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.

3. A Complete Report Timely Concise Makes every word count
Concrete fact with descriptive detail
Clarity
Uses accepted abbreviations
Short sentences or phrases

4. 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

5. Report Writing and the Law

6. 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.

7. 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

8. 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.

9. Documentation Problems
Deficiencies
Discrepancies
Omissions
Treatments & Patient Responses
Unapproved abbreviations
Errors of Omission or Commission
Undocumented information
Incorrect or erroneous information

10. 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

11. 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

12. 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

13. Remember: Keep a copy of your supplemental report for your records

14. 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
Personnel records/Employment applications
Social Security Numbers
Intelligence reports
Witness Identification
RCW
Medical records

15. Confidentiality Personnel Records Fire Investigative Reports
Cause
Evidence
Contacts
EMS Reports
EMS/Provider confidentiality
Patient history
Assessment findings & treatment
Criminal activity involved?

16. Confidentiality Violation
Invasion of privacy
Defamation
Slander
Libel
The improper release of information or the release of inaccurate information can result in liability

17. 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

18. So,Think You Are Protected?
Statute of Limitations
RCW Good Samaritan Laws
Are you covered off duty?
RCW EMS Immunity Act
Generally protected for acts of omission
RCW
Sovereign Immunity Waived
Local government liable for tortuous actions

19. 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

20. 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

21. 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.

22. 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.

23. 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.

24. Effective Report Writing
Some ideas

25. 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

26. 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

27. 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

28. 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.

29. 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

30. 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.

31. 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

32. Medical Incident Report Forms
Some more ideas

33. 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.

34. 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

35. 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.

36. 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

37. 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.

38. 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

39. 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

40. 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.