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Good Documentation Is Your Best Defense

Good Documentation Is Your Best Defense!

November 2000 CEU

by Steve Wirth, Esquire

The Patient Care Report (or PCR as it is now commonly called) is the foundation of all that you do in the field, as it becomes the "official record" of the care you provided. The PCR has significant patient care, billing, and liability ramifications — a few of which we review in this month's column.

The basic purpose of a PCR is to provide the reader with a "picture" of the continuum of care that was provided to the patient from the arrival of first responders to the transfer of care to hospital staff. In a lawsuit, the PCR becomes your "substituted memory" as most liability lawsuits end up in trial years after the situation occurred. Most people have trouble remembering what they did on a particular call a year ago, let alone several years later. Thus, you need a complete and "visual" record of what you found and what you did if you expect to come across as a knowledgeable and credible witness before a jury.

What Others Expect to See
Outsiders looking at your PCR (like a judge or a jury) will expect your records to be similar in quality to those of other health care providers. They will ask questions like the following:

  1. Was it concise but thorough? An incomplete PCR could destroy a good defense case and make you look incompetent. If it is too long and does not create a clear picture of the continuum of care, it could be confusing.
  2. Is it factual and objective? The PCR should not contain your opinions or beliefs, but should instead be an unbiased description of events and observations. Don't leave out the bad stuff, but subjective statements have no place in a PCR.
  3. Is it written using correct terminology, spelling, and abbreviations? Nothing looks worse than a poorly completed PCR that has misspellings and bad grammar. That is a great way to lose credibility with any outside observer. Make certain you use recognized abbreviations that all professionals in the course of the patient's experience will understand. Avoid the use of slang EMS abbreviations, and use a standardized set of abbreviations wherever possible.
  4. Is it organized and legible? A good PCR follows a systematic approach with the most critical information "up front." Care should be documented chronologically. If you are not typing the narratives, you must make sure the PCR is neat and readable.
  5. Is it complete and accurate? You should never put any false information on a PCR, and you should always make sure that all sections of the PCR are completed in their entirety.

    6. The PCR Is a Medical Record
    The PCR is considered a "medical record" and as such, the EMS organization that creates it is the "owner" of the record. As the owner, your service has a duty to safeguard the documents and protect their confidentiality. That means you may not release the PCR or its contents except upon the written consent of the patient, a proper subpoena, or a court order. You should also not discuss the contents of the PCR or anything about the patients you treat and transport with individuals outside your organization. Detailed internal discussions about the specific patients you treat should be at a professional level, respecting the dignity of the patient. Only those with a "need to know" in your organization should be given details about the patient care you provided in a particular case.

    The three most common examples where the PCR may be released to others include:

  6. Insurers and third party payers for reimbursement purposes, when permission to release the information is given by the patient
  7. Legally-authorized research
  8. Litigation where the document has been obtained through proper legal process, such as during the discovery phase of a lawsuit

Common misconceptions have emerged about documentation. You may make changes to a PCR as long as the late entries or changes are clearly identified with the your initials and the date and time that the change or addition was made. The key is to make certain that any late entries or changes after the initial completion of the PCR do not look like they were done contemporaneously with the time you completed it. Errors may be corrected by drawing a single strikeout line through the incorrect text, and then clearly initialing and dating the correction with the time it was made.

Supplemental sheets or "addendum sheets" are also permissible. If you forgot several things when you completed the PCR, fill out an addendum sheet, clearly noting the date and time it was completed, and forward it to the destination hospital and billing department, asking them to attach the addendum to the original PCR.

Refusals: A Different Approach
One of the major sources of liability to the EMS organization is the abandonment of a patient. If you leave the scene without treating and transporting the patient, and the patient suffers further harm or dies, many questions will be asked. Good documentation can greatly limit your liability.

Refusals of care and transport should be documented on the PCR and with a separate "Refusal Form." A separate form is necessary due to the extent of information you must obtain, including documenting the legal and mental capacity of the patient, since only competent patients can legally refuse care. See the June 2000 MERGInet.News feature, "Patient Refusals: Practical Legal Pointers," for more information.

Changes Are on the Horizon
Now more than ever, what you write on the PCR and how you document each patient care event can affect you and your organization in many ways. Good documentation not only is necessary for quality patient care, it can also help ensure adequate reimbursement and help your service avoid liability in a lawsuit. Hopefully, with the advent of the new Medicare Fee Schedule (to be implemented in a few months) will come "condition codes" that will place an even greater emphasis on proper documentation of patient signs and symptoms. These condition codes were recommended during the Negotiated Rulemaking process for the new fee schedule and are contained in the proposed rulemaking recently published. If the Health Care Financing Administration (HCFA) adopts the codes in the final rule, the 93 condition codes will be used in the completion of PCRs and billing paperwork, and will help in better documenting the care you provide. The use of these codes could also lead to more appropriate reimbursement and fewer claim denials.

One final point: Do not implicate other responders in your PCRs. Save that for a separate incident report where it belongs. In one Pennsylvania case, the PCR had entries with statements like "ET tube pulled by BLS." Well, in that case, these conclusory statements raised a big red flag for the plaintiff's attorney, who also happened to be a respiratory therapist before he went to law school. Those entries piqued his interest in taking on the case against the ambulance service and others. Be careful what you write, and how you write it!

Complete and thorough documentation is absolutely necessary for good patient care and is also your best defense in a lawsuit. Remember the adage, "If it's not documented, it didn't happen." This phrase rings truer today than it did even ten years ago. Following some common sense steps in the process can help you down the road if the care you provided comes under scrutiny.

DISCLAIMER: This article should not be relied on as a legal opinion of the author or MERGInet.com and should not be a substitute for legal advice in the confines of the attorney/client relationship. The purpose of this article is to convey general information about current developments in the law.

Sinor EMS Employees (ONLY)-- You can e-mail either address for the test questions if you would like CEU hours.
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