"It was a dark and stormy night,..." Don't all run sheets usually start that way?
My first big trauma run came during my senior year in high school, about 2 weeks before graduation. I'd been an EMT for about 5 months and loved being a part of EMS. Big nasty single car accident with both driver and passenger ejected. Here I was still fresh out of EMT class and learning all that I could get my brain wrapped around. I loved the EMS world and all it had to offer; the skills, the challenges, the patients, everything. I embraced everything with open arms.
About 10 years later I happened to be running around the station and was talking with some people about old runs. That particular run came up and became the main topic. I still remember it vividly and I still have some of the newspaper clippings and pictures in one of my old scrapbooks. As we were talking about it I asked about seeing my old run sheet. "Here's the keys," I was told. So I set out on a mission of rummaging through years and years of old run sheets to find this one needle in a haystack report.
About 30 minutes later I found it. I was shocked. I was dumbfounded. I couldn't believe how I'd done my report. It was all handwritten other than the headings for the certain sections. My narrative? Less than 3 complete sentences. This was a BLS narrative for an ejected passenger, unconscious, decorticate posturing, with shallow breathing and crappy V/S. I know because I remember what I saw because of the run, not from my run sheet.
Since that time I've been to court and given depositions on a handful of cases. I've been talked down to by lawyers, I've been cross-examined by lawyers, I've been made to feel that I don't know what I'm doing in the EMS world by lawyers. It happens. They do it for their clients, not because they don't like or trust me. But one constant comes from every time I've been to court or given a statement; documentation is king.
I was floored at the amount I could recall about this incident and the utter lack of details actually put on paper. Laziness? No time? Education? Were there specific reasons why this was like this? Back then we had to leave our run sheets at the hospital before we left there. On rare occasion we'd finish them later, like if we caught another run before we got done writing it. This one? No clue. I will say that in my EMT class documentation was never harped on or drilled in to our heads.
Fast forward about 1 1/2 years from then. In Paramedic class and again, documentation wasn't stressed. If anything, I learned documentation from my boss who was one of my preceptors. He schooled me in the fine art of documenting a run. All the details, the pertinent negatives, the treatments and responses, the finer points of the scene that were visualized that may have played a part in the patient's history of the present (or past) problem; things that should be documented. I got my run sheets torn apart thoroughly by him on a routine basis, even the BLS transfers I did for him he'd go through with a fine-toothed comb.
While a lot of services and departments are going for ease, efficiency, and time saving measures when it comes to reporting, I'm still and always will be a fan of good documentation and a thorough narrative. I worked for a service a while back that began toying with electronic "notepads" for their run sheets in an effort to reduce paper use and speeding up sending reports to the main office for billing purposes. There was no place for a narrative. None. My questions were these: Does a narrative need to be generated on a BLS nursing home or doctor's office visit? Sure it does. What did you see? Why was there a need for this transfer? Is it not possible that this patient could change in front of your eyes or you see, and document, something that an extended care facility staff member did not? How many times have you heard about people getting calls about missing personal effects a patient had? Ever gotten a call from a facility asking about a hematoma or mark on the patient's body that wasn't documented on the transfer sheets? Guess where the blame will lie on that one.
Has it happened? Yes. The best defense we have is our documentation. Even though we typically only see patients for a short period of time, our run sheets need to paint a vivid picture of what we saw, what we did, and how they reacted to our treatments. Sometimes these run sheets come back to haunt us years after the fact. Can you remember every run you did in 2008? How about 2009? I'm sure there are the memorable runs but what about the mundane ones? Is it not possible that the mundane BLS car wreck on January 4th, 2009 ends up being a court case where someone is getting their pants sued off and you're called to be deposed? Even more, you or your department could be named in the suit for malpractice. Possible? Very. Does it happen? Damn right it does.
Spelling, grammar, punctuation, capitalization all matter on run sheets. I'm not the world's best but I do a fair job of being detailed in my reports. If spelling is wrong you may get called "lazy" by a lawyer for not taking the time to spell check. "Since you didn't use spell check and were lazy in your reporting, were you lazy in treating my patient? Did they get the care they deserved because of your inattentiveness?" Or incorrect grammar and / or punctuation could lead to, "Since you don't care enough to use proper grammar or not use the correct punctuation then you obviously don't care enough about patient care and treating my patient to the best of your ability."
These run sheets may need to be recalled years down the road. Other than pictures our documentation is the best thing we have to help us remember, jog our memory about a particular run. Take your time putting them together. Put pertinent details and the pertinent negatives. Make it easy to read; not necessarily a book, but one huge long paragraph is difficult to digest sometimes. Try to keep things in chronological order; what you saw, what you were told, what you did, how you did "it," what the responses were, end result when arriving at your destination. It's all about CYA. Protect yourself and your department the best you can.
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