If It Wasn't Documented, It Didn't Happen

Many times in my EMS and professional career I've come across that phrase. It's been said to me, I've told it to others, I've overhead others having conversations about it.

For the sue happy world documentation has to be one of the best defenses we can have. I stress upon people all the time that we need to document the most minute details in some of these cases. A lot of areas are going to check boxes and things like that that reduce or eliminate narrative sections. Several years ago when I worked elsewhere they looked at doing that, thereby eliminating what the EMT or EMT-P wrote. Check boxes are simple, quick, and easy but leave a lot to be desired. Of course there are those calls that can easily be documented by ticking a box. But not all.

People have asked me, "have you ever been called to court or been deposed?" Yes I have and it's no fun. I've had runsheets or PCRs torn apart because I misspelled a word, forgot a minute detail, misquoted what the patient said, forgot to get a signature, or didn't use the preferred widely accepted abbreviation.

I'm a firm believer of, "if it wasn't documented, it didn't happen or it wasn't done." I'm in the midst of a suit that happened 2 1/2 years ago. I explained to the lawyer that I was raised writing everything down; what I saw, what I heard, what was said to me, what the scene and surroundings are. If those things are pertinent to the patient, the outcome, or for future reference they need to be written down. I told her that I typically write novels for PCRs because I want to make sure I cover my ass as well as my service's. I don't want anyone to get in trouble because of something I did or didn't do and failed to document.

Crime scenes are especially vulnerable to being called to court. Drunk driving accidents or any car accident is likely to be called to court. Workman's comp cases and jobsite injuries are very common ones where someone sues later for a settlement.

I've seen 4 and 5 sentence paragraphs for an ALS dyspneic patient and I've seen 2 and 3 pages for BLS car wrecks. The people writing them vary as do their styles and the ways they were trained. Their mentors and preceptors may have done different things in their documentation. I tell people to make their own variation of different people to adequately suit their cause and develop their own style. I used to get criticized for taking so long on my reports but I was able to stick it back to my employer the first time I got called to court and had my usually long narrative with me. It allowed me to remember that particular incident 3 years post.

Discussed with some people last week about SORs and their need. Those too are cya things. Ran in to a situation recently where someone didn't want any c-spine or lsb after we'd already placed it on at their request. I asked the patient if they'd be willing to sign an SOR or AMA form releasing us of any liability before it was removed. The response? A quiet, "no." So we went about our job or helping the patient out. There were some special details that needed to be in the documentation but it was needed to help cover us, show what we faced, how we handled it, what we said, what we knew needed to be done yet were not allowed to because of the patient's wishes.

How often do people actually document that a steering wheel was bent? Which direction? Was there damage to the interior of a car? How far did the door protrude in? Which airbags deployed? Did anyone notice the multiple pill bottles on the sink next to the 10 empty alcohol bottles? Ever mentioned about the odor or smell of the inside of the house? Was it pertinent to the problem at hand? What did the patient tell you? Be specific. Quote exactly. What we write on are legal documents and can come back to be your best friend in court,... or they can haunt you.

There are also things like irate parents and family members who spout off things that don't need to be documented but need to be addressed or passed on. Case in point would be a parent who is spouting off everything from the time you walk in to the door to the time you drop off the patient in the ED. But in that brief moment the patient is away from the parent the story changes, the details come out; your treatment may easily be swayed by what you see AND hear from the patient them self. Most people can speak for themselves. Give them the opportunity if you can as it's for their benefit (obviously). I usually try to bring the nurse or staff out of the room / area and discuss things with them so I'm not corrected, told I'm wrong, or make situations worse by that family member. And make sure you document whatever's pertinent.

If it wasn't documented, it didn't happen.