Report WritingA RGT Presentation

Elements of a Good Report

• 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

A Complete Report

Timely

Concise

Makes every word count

Concrete fact with descriptive detail

Clarity

Uses accepted abbreviations

Short sentences or phrases

Why Written Reports?

• 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

Report Writing and the

Law

Legal Definitions

Duty

Breach of Duty

Standard of Care

Scope of Practice

Negligence

Abandonment

Causation

Damages

Most Litigated Issues in Fire/EMS

Termination IssuesHiring Issues

Medical Malpractice Sexual/Nonsexual harassment

Civil Rights ViolationsWhistle Blower Retaliation

Management Relations with VolunteersVehicle Accidents

EMS Liability

Vehicle AccidentsAbandonment

Dropping PatientsEquipment ProblemsPatient Care Issues

Confidentiality

Over 80% of EMS lawsuits are not directly related to patient care.

Documentation Problems

• Deficiencies• Discrepancies• Omissions• Treatments & Patient Responses• Unapproved abbreviations• Errors of Omission or Commission

– Undocumented information

– Incorrect or erroneous information

Modifying Reports

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

Modifying Reports

• 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

Supplemental Narratives

• 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

Remember:Keep a copy of your

supplemental report for your records

Public Disclosure

• 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

Confidentiality

• Personnel Records• Fire Investigative Reports

– Cause– Evidence– Contacts

• EMS Reports– EMS/Provider confidentiality– Patient history– Assessment findings & treatment– Criminal activity involved?

Confidentiality Violation

Invasion of privacy

Defamation

Slander

Libel

The improper release of information or the release of inaccurate information can result in liability

Release of Information

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

So,Think You Are Protected?

• 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

Your Best Defense?

• 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

Accountability

• 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

Documentation

• 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”

Remember!

If you did not write it,it did not happen!

You are hereby summoned ..…

• 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.

Effective Report Writing

Some ideas

A Well Written ReportShould be:

Concise

Clear and well organized

Mechanically correct

Written in standard English

Legible

Completed on time

Written in ink

5 Steps in Writing Reports

• 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

Effective Reports

• 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

Effective Reports

• 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.

Effective Reports

• 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

Effective Reports

• 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.

Effective Reports

• 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

Medical Incident Report Forms

Some more ideas

Medical Incident Report Form

• 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.

EMS Reports

• 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

Flow Chart

• 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.

SOAP Format

• 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

SOAP Format

• 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

SOAP Format

• 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

SOAP Format

• 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