Document the S#*T Out of Every Call

Have you ever seen police or EMTs carrying around little laptops?  They’re called “toughbooks,” and they’re used for documentation by many groups, including the military.

Understandably, EMS is regulated by the government, and has to answer to many different systems: administrative, medical, governmental, and legal.  There’s a saying that is drilled into our heads:
“If you didn’t document it, it didn’t happen.”
Harsh and time-consuming as this may seem, it is greatly helpful when reviewing a call from months or years ago for quality control or legal purposes.  When EMTs are called to testify in court, like in the recent trial of Dr. Conrad Murray (Michael Jackson’s private physician), we do not have perfect recall of all the details of that day.

We write patient care reports (PCRs) for each patient (not just each call).  If we respond to a scene with 5 patients, we have to write 5 reports covering the time up until we transfer care.  The industry is quickly moving to electronic documentation, although when I first started a year ago my company was still using paper.  I’m glad I got to experience both handwritten and digital formats, as I learned quite a bit about the limitations of both systems.

Regardless of format, the PCR is very detailed and begins with documeting the time the call came in to dispatch, and ends with when the crew cleared the hospital after transferring the patient (or after documenting a refusal of care).  We check off loads of boxes from endless subheadings covering the patient’s complaints, everything we find in our assessment, vital signs, medical history, interventions (treatment) we give, and patient outcome.  There is a section at the end where we write a detailed narrative account of the call from start to finish.  In EMS, you’re short on time and often have to document quite a bit, so we often write notes on cards or a notepad (or tape we stick on our pants) as we work, and then transcribe it formally at the hospital.  Shorthand becomes very important, as does learning to decipher your partner’s handwriting (still working on that).

I often catch myself describing calls to coworkers and friends using this notation (a bit like saying “LOL” out loud—very irritating) and even using it to write notes to myself.

Here’s an example of a finished PCR
(There would be many more shorthand abbreviations on the notecards. This is a made up patient.)
A107 →man down at grocery store. O/A FD and PD on scene in parking lot. Pt 55 y/o ♂ CA&O x 3/4  seated next to dumpster c/o numbness in LE BL, + LOC, N/V, dizz, tremors, headache. Pt Ø CP, SOB. + CSMs BL. Hx ETOH abuse.  Pt unsure of fall, states “only” had 1pint rye since 5am, pt denies drug use. Pt Ø head/neck back pain no bumps/bruises/other visible trauma on exam. Pt states he passed out ≈8am, awoken by FD on scene. Pt wearing 5 jackets & hat, extremities & face cold red & dry, torso pink warm & dry. PD removed ETOH from pt, poor grooming, strong aroma of ETOH & urine. Pt poor historian PMH. Hx hospitalizations for AMS, ETOH, SI. Pt Ø SI & HI today. Pt→stretcher x5→ambulance in position of comfort, heat ↑. Vitals a/a. Lungs + rhonchi BL LL only, pupils sluggish BL. Pt ↑agitated. O/A hospital pt→bed x2 rails. Pt care & hx→triage RN, pt well-known to staff. A107 clear Ø incident.

This is a basic call! Imagine the novel I’d have to write for a car accident, where I have to document the scene and the damage to all vehicles in excruciating detail.  I actually like this part of the job… sometimes.  It’s like telling a story.  And I know it could be useful to me in the future (CYA as they say).

What aspects from your job creep into your life?


Leave a Reply

Fill in your details below or click an icon to log in: Logo

You are commenting using your account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s