A RGT Presentation

• 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

Timely
Concise
Makes every word count
Concrete fact with descriptive detail
Clarity
Uses accepted abbreviations
Short sentences or phrases

• 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

Duty
Breach of Duty
Standard of Care
Scope of Practice
Negligence
Abandonment
Causation
Damages

Termination Issues
Hiring Issues
Medical Malpractice
Sexual/Nonsexual harassment
Civil Rights Violations
Whistle Blower Retaliation
Management Relations with Volunteers
Vehicle Accidents

Vehicle Accidents
Abandonment
Dropping Patients
Equipment Problems
Patient Care Issues
Confidentiality
Over 80% of EMS lawsuits are not directly related to patient care.

• Deficiencies
• Discrepancies
• Omissions
• Treatments & Patient Responses
• Unapproved abbreviations
• Errors of Omission or Commission
– Undocumented information
– Incorrect or erroneous information

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

• 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

• 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

• RCW 42.17.260
– 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

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

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

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

• 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

• 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

• 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

• 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”

• 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.

Some ideas

Concise
Clear and well organized
Mechanically correct
Written in standard English
Legible
Completed on time
Written in ink

• 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

• 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

• 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.

• 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

• 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.

• 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

Some more ideas

• 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.

• 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

• 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.

• 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

• 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

• 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

• 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