Clarity of documentation

Posted by Patrick Lickiss on Mar 9, 2011 in General, Legal | 0 comments

I haven’t see this one yet, but I assume it’s just a matter of time.

Clear documentation is a key in our line of work.  Not only does the quality of your chart potentially impact the long-term care of the patient, but it could protect your license and career in the event of litigation.

THE HOSPITAL
Leaving a detailed patient care report at the receiving facility should be considered part of the turnover of care before clearing to go back into service.  Often, patients are unable to answer questions on their own, or small bits of information may get lost along the way.  We work hard on scene to gather as much information as possible and it is our duty to pass that information on.  Consider, for instance, the stroke patient who is suffering from aphasia.  He can’t articulate to the ED staff that time of onset of his symptoms.  But by accurately charting that information or recording contact information for witnesses, you can facilitate the treatment of this time sensitive patient.

THE COURTROOM
Consider also the example frequently given in EMT and paramedic programs:  There you are, sitting in a courtroom, wearing a suit for the first time since your hiring interview.  Projected on a huge screen behind you is your PCR.  Piece by piece, the attorney tears your chart apart.  By the time you’re done, you aren’t sure who doubts your medical judgement more, the jury, or you.

Sure I’m approaching this in an overly-dramatic fashion.  I’ve been fortunate enough (knock on wood!) to avoid testifying so far.  But this story is all too common. The fear of litigation is a real one and writing a competent, clear and consistent PCR is one of your best methods to combat a great deal of stress.

HOW-TO
There are a variety of examples of how to write a good PCR (here’s an oldie but goodie) but with systems moving to ePCR, the best example may be one from your own system.  Data entry methods and final print copies vary so much from program to program that while guidelines may still apply, the exact method can be vastly different, even among agencies in the same county or state.  You know a practitioner who performs good documentation at your service, so ask to see some of his or her PCRs.  Many electronic PCR programs have the ability to print copies which are stripped of patient identifiers (called Intern PCRs in my system).  This will allow you to read narratives and treatment sections and incorporate the aspects which work best for you.

When I first started doing QA/QI work, one of my tasks was reviewing “critical” PCRs for completeness.  By reading PCRs written by basically every paramedic at my service I was able to vastly improve my documentation.  And that was without taking a single class or attending one documetation workshop.

So how about you?  What have you done in your service to improve your documentation?  Chart review?  Peer-based run reviews?  Anything else?

Image via Married to the Sea (a hilarious read!)