If you omit something on a prehospital care report (pcr), what should you do?

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Question: My partner is a terrible writer. When it’s his turn to write the narrative for the ePCR every sentence has multiple grammar errors and misspellings. Important details about assessment and care are often left out. I’ve tried to make corrections, but he always wants me to just “sign the dam report” so we can clear the hospital for quarters or the next call. He’s also the crew chief so it’s not easy for me to call out his poor writing skills. As a co-signer am I liable for his mistakes? How can I make sure we have more accurate and more professional narratives without turning him against me?

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Answer: Wow. The worst part about your question is that it is so common in EMS. What you are experiencing is happening everywhere – despite my best efforts to the contrary.

The short answer to your long question is: yes, you may be considered liable for the mistakes contained in the patient care report if you are cosigning as to its accuracy.

The longer answer is far more troubling.

Since our parents’ and grandparents’ time, grammar, spelling, table etiquette, work ethic, and the like were ingrained into us and reinforced daily. Dangling participles and elbows on the dinner table were often met with the same response. Lazy work was not tolerated.

Over the years, though, we have grown lazy and complacent. Everyone gets a trophy, and nobody fails in school, so we simply don’t care as much about once-important notions like spelling, grammar and etiquette. Work ethic seems to have gone the way of the dodo. It stands to reason that complacent EMS providers and grammatical and spelling errors are all too common in patient care reports.

EMS partners are a team

The more sinister issue you point out; the much, much bigger problem that will directly affect you is the reality that “…[i]mportant details about assessment and care are often left out…” of his reports. My experience has been that omissions in documentation equate to omissions in care and that is what will bring you both down. It does not have to be true, it only needs to appear true.

The law views EMS partners as a team; each provider is responsible for the [known] conduct of the other. For example, if you are both paramedics and you see your partner about to commit a treatment error and you don’t intervene, it is as if you made the error.

Likewise, if you know or should know that your partner is documenting improperly or incompletely or, worst of all, fraudulently, and you do not intervene, it is as if you committed fraud. You will both be sanctioned equally. Any documentation you sign off on, whether you wrote it or not, whether you read it or not, you own everything in it and everything that is missing.

Partners solve problems together

How you fix this problem without straining the relationship is delicate work until it is not.

Partners are supposed to have each other’s backs. Partners are supposed to look out for one another. Partners are supposed to protect each other, even when doing so may be uncomfortable. The partner who drives you to be better is the partner you know you can trust. The partner who expects you to lie for him or her is the one you know you cannot trust; that is the one who will burn you before he burns with you.

Your crew chief partner is not acting like a crew chief, much less a partner. I don’t know him or his personality, so I cannot tell you definitively how to handle it. I can give you a couple of options:

Talk to him, partner to partner.

“Hey, I understand wanting to go available faster. The problem is that our duty to the patient we just transported is not satisfied until we have provided the kind of accurate, complete, and thorough documentation that affords the patient and the hospital the best opportunity to provide continuity of care.”

(That is a lot of words. Convey the message in your own words).

Maybe your attention to quality will be contagious; problem solved. Maybe not.

Maybe the conversation needs to be a little more direct.

“Incomplete documentation is bad for the patient, makes us both look bad, and can come back to haunt both of us. Making sure that the ePCR is as good as it can be is not a ding against you; it’s me being a good partner and us doing right by the patient.”

If the diplomatic route fails, stand your ground. A wise person once told me that doing the right thing is not always easy, but it is always the right thing. You may need to get tough, go over his head; you may need to drive the culture of your agency to a better place; a higher standard.

You will hit resistance. My feeling about providers who resist improvement is that they don’t belong in EMS.

The conflict you are facing with your crew chief is the same conflict that countless EMS providers face every single day. Hopefully, your question and this answer will help you and them, too.

What are your thoughts on how to solve this problem? If you are a weak writer, what feedback from your partner would be most helpful to you?

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Do you have an EMS legal question for me? Email me and I will consider it for an upcoming EMS1 column. Note: I am only licensed to practice law in California. Any response to hypothetical questions is intended for educational purposes only and is not intended to be nor should it be considered legal advice. 

The prehospital care report or PCR (also ePCR when in the electronic format) serves as the only record of each individual patient contact, treatment, transportation, or cancellation of services within each EMS service.

CONTINUITY OF CARE: The PCR, when completed accurately and fully detailed, is used for continuity of care between EMS and the destination facility, for administrative services such as billing, and can also be utilized as a legal document in courts of law proceedings.

PCR: 

• Each PCR should include all pertinent times associated with the EMS call.
• As well as the times of the assessments and treatments provided, the PCR should include detailed signs and symptoms and other assessment findings such as vital signs, and all the specific emergency care provided. 
• Also documented are changes in patient condition after treatment.
• Any pertinent observations from the scene may be important for patient care or for legal purposes, requiring detailed recording in the PCR with the notion of future use.
• The patient disposition is also recorded, including who patient care was turned over to (usually a nurse at a receiving hospital) or a patient refusal.

Report Writing

Patient care reports should include what is known as a minimum data set, or the absolute least amount of information possible, to facilitate correct tracking of EMS data by the National EMS Information System.

MINIMUM DATA SET: two separate types of data that are recorded,

1. PATIENT INFORMATION:

• chief complaint,
• the initial assessment,
• vital signs, and
• patient demographics.

2. ADMINISTRATIVE INFORMATION:

• the time the incident was reported,
• the time the responding unit was notified,
• the time of arrival at the patient,
• the time the unit left the scene,
• the time of arrival at the destination, and
• the time of transfer of care.

All times being required mandates accurate and synchronous clocks across the entire EMS system

SOAP NOTE: Traditionally, the SOAP method is used for narrative documentation and includes all pertinent information. SOAP is an acronym for a patient care report that includes:

• Subjective: details relative to the patient's experience of the illness or injury like onset time, history, complaint, etc.
• Objective: data that can be verified or observed by multiple people and get the same results, such as vital signs, lab values, and physical exam findings.
• Assessment: analysis of the problem based on subjective and objective data.
• Plan: the treatment that should be carried out in the best interest of the patient.

ERROR CORRECTION: Errors discovered while the report form is being hand-written should be corrected by drawing a single horizontal line through the error, initialing it, and writing the correct information beside it.

► EMS professionals should never attempt to obliterate the error because this could be interpreted as an attempt to cover up a mistake.

Errors discovered after a handwritten report form is submitted should be corrected, preferably with different color ink, by drawing a single line through the error, initialing and dating it, and the addition of a note with the correct information. If information was omitted, a note should be added with the correct information, the date, and the initials of the EMS professional.

Errors discovered while/after completing an electronic patient care report should be corrected within the ePCR system when possible, through the amendment or addendum portion of the program used.

If there is no way to electronically submit a change or addendum, and EMS professional should follow the correction method used for a handwritten report that has already been submitted on the printout of the electronic report.

Judging vs Judgment

Don't judge. 

Example: Don't write that the patient was "drunk." However, you should report slurred speech, smell of alcohol on his/her breath, and lack of coordination. You should also document in quotes any statements/confession, e.g., "I am so wasted!" THEN, use judgment for how to proceed, based on the objective findings/documentation. 

Documenting Patient Refusals

Competent adults always have the right to refuse medical treatment.

In the instance that a patient is attempting to refuse treatment or transport by Emergency Medical Services, an EMS professional should ensure the patient is able to make a rational, informed decision.

• EMS should inform the patient why he/she should go and
• what may happen to him/her if he/she does not.

Keep in mind that online medical control can be consulted as per local protocol. If the patient still refuses, the EMS professional should thoroughly document any assessment.

• A signature of a witness to a patient refusal is always recommended, preferably a family member, police officer, or bystander.

If the patient refuses to sign the refusal form, have a family member, police officer, or bystander sign the form verifying that the patient refused to sign--as well as refused treatment/transport.

The patient care report should still be completed and should include a complete patient assessment (as complete as was performed), as well as documentation supporting the refusal of care and/or complete assessment.

• Documentation should include any care or treatment plan the EMS professional wished to provide for the patient, and the statement that the EMS professional explained to the patient detailing possible consequences of failure to accept care, up to and including potential death.
• The EMS professional should always offer alternative methods of gaining medical care for the patient and state the willingness of EMS to return to treat and transport the patient if he/she were to have a change of mind.
• Before an EMS professional leaves the scene, he/she should try again to persuade the patient to go to the hospital.