Oh, I’m in the midst of it. The case is currently in litigation.
it take no time at all to write. Why not just just note what you did? And this comes from documentation classes from PWW and JR Henry. (Look em up)
If you think the attorney that is working to get millions from your insurance and will just roll over when you say ”well, we always do that” you are sorely mistaken. Especially if the second provider on the ambulance says “he usually uses all the straps”. Usually. That is no good.
One of the biggest myths in EMS is that too much documentation will get you in trouble. If you’re acting within your scope and in the best interest of the patient, there is no case where documentation of your patient care will come back to bite you. I see this all the time from “seasoned” providers.
As an example, I was part of an investigation of a case of malfeasance that was so poorly documented there was no way the paramedic could defend himself. He left out much of the vital information that could have potentially helped him. He said “I didn’t want to write to much” If he had actually written more, he might have saved himself.
interesting... you have a person who answered this? I have a question I would like to direct to them too, to hear their opinion. Using your example, where the response is "well, we always do that" is not acceptable, if you don't document that you didn't sexually assault the patient, does that mean you did? I mean, the response when asked will be "well, we never do that." Esp when the attorney will find articles where EMS providers have sexually assaulted patients, so you can't say it's never done. Yes, it's an extreme example, but that's the exact logic you used.
I never said more documentation will get you in trouble, I said "more documentation is not always better, and too much documentation can sometimes just waste your time, and not provide any real benefit." Documentation is good, and we should document what we did. And I don't expect any attorney to ever roll over, but that doesn't mean if you say it your attorney is going to start adding zeroes to the check; that's the difference, one you seem to be missing. and if you think the attorney is going to roll over when you write "patient was secured by 5 straps", especially if the second provider on the ambulance says “he usually uses all the straps” well, you are in the same boat.
Document your clinical interventions. what you found, and what you did. applying seatbelts on a cot isn't a clinical intervention, no more than documentation how many blankets you put on a patient because it's 12 degrees outside and snowing. I mean, you don't write on your PCR when you get cut off by another car, resulting in a hard stop, do you? especially if it doesn't affect the patient? Do you understand?
As an example, I was part of an investigation of a case of malfeasance that was so poorly documented there was no way the paramedic could defend himself. He left out much of the vital information that could have potentially helped him. He said “I didn’t want to write to much” If he had actually written more, he might have saved himself.
Sounds like your provider wrote a crappy chart. sorry. did they neglect to write that the patient was secured with the shoulder straps, and that is why you are going to lose the case? or did the paramedic neglect vital information about the patient's condition, and that is why he is unable to defend himself? remember quality vs quantity: there is a difference between a good chart with the correct patient information and a long chart with a lot of irrelevant content, but missing the correct patient information.
let me be clear, since you seem to missing the big picture here: you can write a whole lot of nothing on a chart. pages and pages. does it hurt to over document? no, and I never said it would get you in trouble. I said it didn't provide the benefit you are claiming, and it just wastes your time. But it's your time to waste, and if you want to keep pushing the (false) belief that the opposing attorney is going to just roll over because you wrote it on the PCR, then I think you are sorely mistaken.
