EMS Documentation Pearls | Part Two

This episode on EMS Documentation is part two and goes a little more into detail when thinking about what and how to properly document your patient care as a paramedic.

 


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EMS Medical Terminology | Directional Terms

Using proper medical terms in EMS allows you to explain and discuss what is going on with your patient as well as aid in good documentation. Directional terms are some of the basics but also some of the most used.



Justifying Your Actions

I was thinking about something that many of us do in variations

Too much, too little or not at all.

Justifying your actions or in many cases in-actions is an important part of not only your documentation but in your treatment and report to the emergency department.

If you do not provide a standard treatment modality, you need to document and be able to verbally substantiate why you did not do it.
If you go beyond basic treatments and perhaps even beyond what is an accepted treatment. You must be able to justify why you did it.

Many instances can dictate why things are omitted during treatment. It can be an uncooperative patient, a patient’s refusal of certain treatments i.e. nitroglycerin because it gives them headaches, your clinical impression vs. protocols, time constraints and possibly even safety issues.

All of these can lead you to not perform what would otherwise be considered standard treatment. The pre hospital environment does not always lend to perfect conditions and you may be questioned on why you couldn’t intubate someone or why you didn’t give a certain medication.

I never judge other pre hospital providers for not doing something. I wasn’t there and I don’t know the circumstances. It’s very easy for others to be backseat drivers and say what should have been done.

The key is to be able to justify your actions and to allow them to be scrutinized. If your treatment and documentation can hold up to others evaluations, then you properly justified your actions.

At the same time, you must not do any harm to the patient. If less than optimal conditions exist in the field, which they usually do. You need to make choices that will most benefit your patient.

The primary concern is to always go back to your basics of ABC’s. Treating the patient with a vectored exam and performing critical tasks first will always allow you to justify your actions.

Decisions we make in the field can affect the outcome of the patient. The idea is to do no harm. Sometimes that may mean a simple transport to the hospital and respecting the patients wishes. By documenting and justifying what you did or did not do, you protect yourself from questions that may arise later. Too many of us do not document enough and leave  ourselves open to problems down the line that could be prevented with a few words on our report.

Justifying why you went beyond what is an accepted practice will require even more careful documentation. But the same principle will hold true. If it can hold up to the scrutiny of others, then your actions will be accepted.

Scenarios of going beyond accepted policies and of not doing enough are plentiful. We all have heard the stories, but remember – we were not there. It is left up to the individuals involved to justify what they did.

Will they hold up to our scrutiny?  More importantly, will our actions hold up to theirs.