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![Documentation Purposes
Legal
• First Ambulance visit
• Two paramedics – one “taking the lead” and doing most of interaction, but both “working as a team”
• Run sheet stated they were called for syncope with nausea and vomiting
• Present Finding: Upon arrival found 57 year-old caucasian female seated on couch. Noted vomitus on
floor. Patient stated had eaten burger from Burger King approximately one hour prior to going for a
walk. Patient denied any chest pain or any medical history. Patient stated that when she returned to
the house, she became dizzy, light-headed, and nauseated. Husband stated he assisted her to the
floor in kitchen. Patient's skin cool and diaphoretic [or sweaty]. Patient AOX3. Patient stated she felt
she was fine after vomiting. Blood pressure was taken[.] . . . Patient again stated felt fine and refused
transport to hospital for evaluation.
• Family alleges patient told them she “was having a hard time breathing”, and they were told about left
arm and shoulder pain earlier.](https://image.slidesharecdn.com/wdesdocumentation-3rddraft-230906144848-f111966d/85/EMS-Documentation-17-320.jpg)
![Documentation Purposes
Legal
Second Ambulance Visit
• Paramedics left, family assisted her to bathtub to help with “heat related” illness.
• Patient helped to couch after bath, then started gasping for breath and shaking.
• 911 reactivated. Same crew responded at appx 800 (presumed PM)
• Present Finding: Upon arrival found 57 year-old caucasian female lying supine on couch
pulseless [and hardly breathing]. No CPR in progress. Patient had been dizzy and nauseated
earlier this evening. Patient moved to the floor. Cardiac monitor shows ventricular fibrillation.
Patient is pale and [sweaty] but warm. Negative abdomen distention. Patient is incontinent.
Pupils equal at four millimeters and non-reactive. No available history or findings at present.](https://image.slidesharecdn.com/wdesdocumentation-3rddraft-230906144848-f111966d/85/EMS-Documentation-19-320.jpg)
![Documentation Purposes
Legal
• In the blank section Crew member wrote
• "Advised to suck on ice chips, take a tepid water bath to cool down and relax.“
• Later this was added "Possible heat related disorder versus syncope of unknown etiology versus possible cardiac
problem.“
• One crew member stated this was written after she signed the refusal, the completing crew member stated it was
included prior to signing.
• Admitted it wasn’t read word for word, didn’t recall advising her it could be life threatening, didn’t recall telling her it
could be a heart problem
• When asked if they tried everything to convince her to go, one medic responded with “It is not my job to convince
you. All I'm there . . . to do is to inform you of the possible injury or medical condition that you have. And if you are
coherent enough and you can make your decision . . . it's your decision whether you consent to . . . [being] treated
and transported.”
• When husband asked if patient was recommend to be transported, He stated “they didn’t recommend it, they just
asked if she wanted to go”](https://image.slidesharecdn.com/wdesdocumentation-3rddraft-230906144848-f111966d/85/EMS-Documentation-22-320.jpg)
More Related Content
EMS Documentation
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- 7. Documentation Purposes Legal DeTarquina V.Jersey City EMS In the case of DeTarquino v. Jersey City EMS, an Advanced Life Support (ALS) crew transported a patient who had been injured during an assault to a local community hospital, they were evaluated and then discharged. The patient later experienced a grand mal seizure and, after EMS was called again, was this time transported to a trauma center. The patient subsequently went into a coma and died of an intracranial bleed.
- 8. Documentation Purposes Legal DeTarquina V.Jersey City EMS The patient’s family brought suit, alleging that during the course of treatment and transport by the first EMS crew, the patient had vomited, but the crew had negligently failed to document that fact on their PCR. The lawsuit alleged that this documentation oversight was critical, because documenting the fact that a head-injured patient had vomited could be a sign of a potentially serious head injury, and had it been documented, the initial hospital would not have discharged the patient. The Court of Appeals agreed, finding that allegations of negligence specific to EMS documentation can be stated separate and apart from allegations regarding negligent patient care. As a result, the court ruled that the qualified immunity for acts of negligent care do not protect EMS caregivers when it is alleged that their documentation was negligent. In short, this case cautions us that there is a separate and distinct standard of care for EMS documentation, and that your documentation can be negligent even when your patient care is not.
- 9. Documentation Purposes Legal • DeTarquinaV. Jersey City EMS • Patient vomited in presence of providers • EMT’s didn’t pass on the fact he vomited • Narrative included notation (–N/V) • Crews were found negligent, not in their care, but in their documentation of care • Appellate court determined that while EMS was provided immunity of liability for civil penalties, this only covered the act of care, not the documentation that follows. • They opined that while the direct care involved more difficulty to perform than by a physician in a hospital, but the resulting documentation doesn’t involve that difficulty, therefore, it isn’t covered under the NJ qualified immunity statute.
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- 11. Documentation Purposes Legal Henslee V.Provena Hospitals In yet another case, Henslee vs. Provena Hospitals, the court found that numerous documentation deficiencies — including a crew’s omission of failed intubation attempts — constituted evidence of deviation from their clinical protocols, which rose to the level of gross negligence. This case tells us that sparse or poor documentation — including notable deficiencies of issues that should be addressed in a PCR (like all treatments and interventions provided or attempted, even if unsuccessful) can deprive EMS providers of the defense of qualified immunity and directly lead to liability. https://casetext.com/case/henslee-v-provena-hospitals
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- 15. Documentation Purposes Legal Browning vs.West Calcasieu Cameron Hospital A court invalidated a signed patient refusal of care form because the crew had not taken the time to explain to the patient the risks of refusing care. In that case, a woman had refused care, despite showing signs that could have indicated a potential myocardial infarction (MI). The crew minimized the patient’s symptoms, saying that she was probably “minding the heat,” and obtained a signature on their refusal form. Since the court found that the crew failed to apprise the patient of the risks of refusal, however, the release of liability language on the refusal form did not protect the EMS providers. https://casetext.com/case/browning-v-west-calcasieu?
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- 17. Documentation Purposes Legal • FirstAmbulance visit • Two paramedics – one “taking the lead” and doing most of interaction, but both “working as a team” • Run sheet stated they were called for syncope with nausea and vomiting • Present Finding: Upon arrival found 57 year-old caucasian female seated on couch. Noted vomitus on floor. Patient stated had eaten burger from Burger King approximately one hour prior to going for a walk. Patient denied any chest pain or any medical history. Patient stated that when she returned to the house, she became dizzy, light-headed, and nauseated. Husband stated he assisted her to the floor in kitchen. Patient's skin cool and diaphoretic [or sweaty]. Patient AOX3. Patient stated she felt she was fine after vomiting. Blood pressure was taken[.] . . . Patient again stated felt fine and refused transport to hospital for evaluation. • Family alleges patient told them she “was having a hard time breathing”, and they were told about left arm and shoulder pain earlier.
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- 19. Documentation Purposes Legal Second AmbulanceVisit • Paramedics left, family assisted her to bathtub to help with “heat related” illness. • Patient helped to couch after bath, then started gasping for breath and shaking. • 911 reactivated. Same crew responded at appx 800 (presumed PM) • Present Finding: Upon arrival found 57 year-old caucasian female lying supine on couch pulseless [and hardly breathing]. No CPR in progress. Patient had been dizzy and nauseated earlier this evening. Patient moved to the floor. Cardiac monitor shows ventricular fibrillation. Patient is pale and [sweaty] but warm. Negative abdomen distention. Patient is incontinent. Pupils equal at four millimeters and non-reactive. No available history or findings at present.
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- 21. Documentation Purposes Legal I admitthat the above refusal is against the advice of the personnel of West Calcasieu Cameron Hospital Ambulance Service who have advised me of the dangers which may result from my refusal including, and not limited to the following: ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ ___. I realize that my refusal may cause or increase danger to myself or the patient. Nevertheless, I assume the risk and accept the consequences of my refusal. Furthermore, I do forever release and give up any claim, demand or action against West Calcasieu Cameron Hospital Ambulance Service, and any and all persons employed by or responding with any fire unit, rescue squad, police or ambulance unit, and do hereby covenant and agree to hold such persons and entities harmless from any claim, demand, loss or action, by myself, the patient, or any person claiming by or through myself or the patient for any alleged act or omission in the care or treatment of the patient in compliance with the refusal. This release is binding on my heirs, executors, and assigns.
- 22. Documentation Purposes Legal • Inthe blank section Crew member wrote • "Advised to suck on ice chips, take a tepid water bath to cool down and relax.“ • Later this was added "Possible heat related disorder versus syncope of unknown etiology versus possible cardiac problem.“ • One crew member stated this was written after she signed the refusal, the completing crew member stated it was included prior to signing. • Admitted it wasn’t read word for word, didn’t recall advising her it could be life threatening, didn’t recall telling her it could be a heart problem • When asked if they tried everything to convince her to go, one medic responded with “It is not my job to convince you. All I'm there . . . to do is to inform you of the possible injury or medical condition that you have. And if you are coherent enough and you can make your decision . . . it's your decision whether you consent to . . . [being] treated and transported.” • When husband asked if patient was recommend to be transported, He stated “they didn’t recommend it, they just asked if she wanted to go”
- 23. Documentation Purposes Legal • Previouscases found and copied from the following sources • https://www.zolldata.com/blog/lessons-learned-from-ems- documentation-legal-case-studies • https://casetext.com/case/henslee-v-provena-hospitals • https://casetext.com/case/browning-v-west-calcasieu?
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- 29. Recipe for GoodDocumentation
- 30. Recipe for GoodDocumentation Accuracy
- 31. Recipe for GoodDocumentation
- 32. Recipe for GoodDocumentation Completeness
- 33. Recipe for GoodDocumentation ACCURACY COMPLETENESS THOROUGH NARRATIVE
- 34. Recipe for GoodDocumentation Narrative
- 35. Recipe for Good Documentation Accuracy Completeness ThoroughNarrative Spelling/Grammar
- 36. Recipe for GoodDocumentation Spelling and Grammar
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- 74. Narrative DACHARTE Method D – Dispatch A– Arrival C – Chief Complaint H – History A – Assessment R – Treatment (RX) T – Transport/Hospital E - Exceptions
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- 77. Narrative DACHARTE Method D –Dispatch A – Arrival
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- 79. Narrative DACHARTE Method D –Dispatch A – Arrival C – Chief Complaint
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- 81. Narrative DACHARTE Method D –Dispatch A – Arrival C – Chief Complaint H – History
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- 83. Narrative DACHARTE Method D –Dispatch A – Arrival C – Chief Complaint H – History A – Assessment
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- 85. Narrative DACHARTE Method D –DISPATCH A – ARRIVAL C – CHIEF COMPLAINT H – HISTORY A – ASSESSMENT R – TREATMENT (RX)
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- 87. Narrative DACHARTE Method D –DISPATCH A – ARRIVAL C – CHIEF COMPLAINT H – HISTORY A – ASSESSMENT R – TREATMENT (RX) T – TRANSPORT/HOSPI TAL
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- 92. Refusal Similar totransport narrative, with the following exception Clear Documentatio n of mental status Not under influences of intoxicants Ability or comprehend risk, consequences , and benefits of accepting transport Has been told risk and consequences and benefits of accepting transport Understands the limitation of our evaluations, and it is in their best interest to see a physician Potential of worsening condition and/or death Most Liability
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- 104. Refusals Things not tosay or Do
- 105. Refusals Things to sayand do
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- 108. Signature • Both Providerswho transported, AIC and Driver Provider signature • Preferred to be the person assuming care/who took report for the patient Facility Signature
- 109. Signature Drug Waste Signature •Nurse or Pharmacy representative witnessing waste Drug Box Exchange • Nurse or pharmacy representative exchanging box (where applicable)
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