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Permalink Reply by Brennan on April 13, 2011 at 4:28pm

For some reason this did not come up the first post. Lets try this...


At my department we are all EMT-B and only do first response. We don't transport because it is done by another agency. Currently we have relaxed reporting system for what we put down in our fire reports for the state. In the narrative we include age, reason for call and transport destination. Maybe a little more if we feel it is needed. That’s about it for information...

I work as a Paramedic for a Ambulance service and our reports are extremely detailed. However I understand they are used more for medical records, pt charting, billing and legal issues.

If you are on a department such as ours please share how you do your reports and how detailed you get. I feel that we should be doing a better job, but want to make sure it’s not just me thinking this. Also are there any standards that we should meet with our EMS reports? I don’t think there are but want to check anyway.

Thank you

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Permalink Reply by Eric Gregory on April 14, 2011 at 9:57am

Doesn't sound adequate to me. What do you do when there's a malpractice suit filed and you have to go back and prove that your actions upon arriving were appropriate and adequate? If it's not documented it didn't happen.

You could still do a short report with some more details.

For Example
Paged to Patient w/ shortness of breath and chest pain. Arrived at ##:## patient concious and alert. Provided o2 and monitored patient until EMS arrived at ##:##. Helpee package patient and went 10:97.

OR

Paged to patient w/ large laceration and heavy bleeding. Arrived at ##:## patient had R hand wrapped in towel. Removed towel and observed 1 inch long laceration on R inside wrist with apparent venous bleed. Covered w/ 4x4 gauze, elevated R arm and applied pressure to control bleeding. EMS arrived @ ##:## and asssumed patient care.

Short, sweet but it contains the pertinent details that document what you did.

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Permalink Reply by Derek R. on April 14, 2011 at 11:38pm

We have the same here, Ralph. WE're a non-transport outfit too, and we still fill out a full pcr. Not only what you did, but how many times you did it and the time interval between them. There's a space for time of arrival of paramedics as well as their unit number.
Can't have too much information. Some day, 3 years from now, you may get that call to court for your detailed memory of the event. At least you have something to go by. Even if it does get picked apart down to the actual fiber that the paper is made out of.

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Permalink Reply by Brennan on April 18, 2011 at 6:26pm

Thats what I wanted to hear. I am working on updating our run sheets as we speak.

Thanks for your help!

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Permalink Reply by 4RC1 on May 12, 2011 at 7:14am

You info is terrific and I agree with your sample naratives, But do remember the burden of proof is not yours if you get sued. Good doccumentation will help for sure!

I had a ems supervisor once who would freak out if you did not write that you put a blanket or sheet on the patient and a pillow for thier head....even on transfers!!!

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Permalink Reply by Eric Gregory on May 12, 2011 at 9:20am

" the burden of proof is not yours if you get sued." That's a nice sentiment and while on paper it's the way our judicial system is supposed to work if you really believe that's the way it goes then you really need to get out more.

If we get sued there's a good chance it will be part of a larger medical malpractice suit. There are a lot of people who are very "anti-medical establishment" out there and if you've got a few of them on your jury you'd better damn well be ready to "Prove your innocence" because you can't count on a presumption of innocence. Remember also that in a civil suit the burden of proof carried by the plaintiff is much lower than in civil cases anyway.

Good documentation is not just something that "Will help for sure", it's an absolutely necessity. If someone is not keeping good documentation and they do get sued I'd give you strong odds that they're going to lose.

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Permalink Reply by Oldman on May 12, 2011 at 10:17am

I would seek the advice of legal council. In many states, fire response reports are public record, while a patient care record is not. There could be patient confidentiality concerns which need to be addressed.

My department does patient transports, so our fire response report does not include any patient information or treatment given prior to ambulance arrival, other than "assist EMS". All treatment rendered by me or my crew prior, is documented on the PCR completed by the medics.

Now, there have been calls where I felt something "wasn't right" on a call, or was the type of call almost destined to go to court, I would get back to the station and write a more detailed report. This report however is not attached to the fire response or PCR, but rather kept filed away,(on my computer)in case an issue arises 2 - 3 years down the road.

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Permalink Reply by mike chappell on May 12, 2011 at 12:03pm

look at this site if you need record keeping ideas for your department.

www.firestationsoftware.com

tell them Mike sent you!

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