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Report Writing. A 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.

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Report writing

Report Writing

A RGT Presentation


Elements of a good report
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
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
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

Report Writing and the Law


Legal definitions
Legal Definitions

Duty

Breach of Duty

Standard of Care

Scope of Practice

Negligence

Abandonment

Causation

Damages


Most litigated issues in fire ems
Most Litigated Issues in Fire/EMS

Termination Issues

Hiring Issues

Medical Malpractice

Sexual/Nonsexual harassment

Civil Rights Violations

Whistle Blower Retaliation

Management Relations with Volunteers

Vehicle Accidents


Ems liability
EMS Liability

Vehicle Accidents

Abandonment

Dropping Patients

Equipment Problems

Patient Care Issues

Confidentiality

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


Documentation problems
Documentation Problems

  • Deficiencies

  • Discrepancies

  • Omissions

  • Treatments & Patient Responses

  • Unapproved abbreviations

  • Errors of Omission or Commission

    • Undocumented information

    • Incorrect or erroneous information


Modifying reports
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 reports1
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
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
Remember:Keep a copy of your supplemental report for your records


Public disclosure
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
Confidentiality

  • Personnel Records

  • Fire Investigative Reports

    • Cause

    • Evidence

    • Contacts

  • EMS Reports

    • EMS/Provider confidentiality

    • Patient history

    • Assessment findings & treatment

    • Criminal activity involved?


Confidentiality violation
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
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
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
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
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
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
Remember!If you did not write it,it did not happen!


You are hereby summoned
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.



A well written report should be
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
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
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 reports1
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 reports2
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 reports3
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 reports4
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 form
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
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
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
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 format1
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 format2
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 format3
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


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