Thursday, June 15, 2006

Documentation Evils

Paper work, paperwork, paperwork, if you didn't write it down, it didn't happen.

They have been preaching this to you since you were in school for your basic card.

I have noticed a few things in my years as an EMT and I think this is a good time to talk to you about a couple of my pet peeves. The "by the book report writer" and the "forecast report writer".

By the book report writer:

This is the guy that can have 40 thousand things go wrong on his scene and when you read his report it's as if he was teaching a class on the proper way to do things. They are marched out step by step in his report perfectly, just as you would see them in the EMS book. Everyone that was on the scene knows it didn't happen the way he wrote it, but none the less it looks pristine.

Come On! We are not stupid, everyone knows that the scene NEVER goes the way the book states, and to make your report look like it did only undermines EMTs everywhere. Tell the truth! A doc would always choose an accurate report of the actions at the scene over a "pretty" fabricated one. Sure you might have done everything you wrote in your report, but it sure as hell didn't happen the way you wrote it.

The Forecast Report:

This type of report writing is very common with non-emergency transport and I have heard of it being utilized a lot. This is the guy who will sit and write his entire report (usually minus the vitals) before he even sees the patient or will write it in the first 10 minutes of patient contact and then just sit in the truck for the rest of the trip. It could be a 1-2 hour trip and his paperwork will be done in the first 10 minutes.

Come On! You cant possibly tell me that there was absolutely no change in the patients status in 1-2 hours, further more you're "guessing" about the patients continued condition during your trip. What if the patient starts complaining of pain that they didn't have when you started transport? What if the patients becomes incontinet or vomits? What if the patient makes comments that you need to document. If your report is already done, I doubt very seriously that anything but a full arrest will get you to rip up your old report and start a new one!

Now that I have vented, lets hear what you have to say!



capnmedic said...

You laugh but there was a place i worked where we got told by the boss what the vital for our transports were going to be that day. I finally left there when i wrote the vital for a body transfer and ended the report with I QUIT. Besides whats wrong with forcasting? Yes patients will change, and its a gamble if you will have to rewrite the trip or not. But there are patients who sleep, drool, pee or stare off in to space through the rear windows for hours on end without change and its an easy trip to write.

Zer0 said...

You are absolutely correct, those type of patients exist however my question remains... lets say you have a catatonic patient on a 1 hour transport and suddenly he speaks.. It's not alot, but it's speach none the less. Are you going to rewrite that report to incluse the fact that a normally catatonic patient spoke to you?


capnmedic said...

Obviously I would make the effort and rewrite the trip sheet and then get ready for whatever facility I am transporting to to not believe me. That kinda ties in to your next blog entry dont ya think?

tdmason said...

Whenever transporting a patient to another facility it is possible to write a majority of the report soon after transport begins. After getting the patient's v/s and making sure all the equipment and/or drips are in order I will start documenting the patient's diagnosis, why the patient is being transferred and what treatment has been rendered and what will be rendered during transport. I will note any changes in patient condition during transport and all v/s. There is nothing forecasting about this. This is only possible if the patient is stable enough for me to do documentation.