这written word has launched a thousand ships; declared an independence; started or ended a war, created contracts, written poetry, novels, classic novels and in general is a method of communication between two people or thousands of people. The written word has existed since the dawn of time with cave drawings and eventually languages finding an ability to communicate with each other. Personally, I have written thousands of words since I first learned how to write and even today, I write on a daily basis as an attorney, a medical provider or just a letter to my kids.
Wearing my attorney hat, I’m appalled at some of the written material I have reviewed related toemergency medical services (EMS)cases involving complicated or simple medical care resulting medical malpractice, death or severe disabilities for patients seen by EMS providers.
这short story is, writing a complete narrative or fire report will “save your bacon” during times of litigation. Writing a medical or fire report is a simple process of following the rules of document completion when working with patients for those important 15-20 minutes or as a result of a fire you fought and extinguished. Telling your story in your words is important.
Why document? It’s required by your department and probably the health department in your state and our memory is fallible. Your memory is especially fallible when your case comes to court, usually just at the end of the statutory period. For example, in Washington State the statutory period is three years for medical malpractice or longer in other civil or criminal cases. Documentation is your recall memory.
您记住与火灾响应或EMS调用有关的细节的实际记忆需要多长时间？大多数专家会说我们的确切记忆大约是两天，以记住任何呼叫或事件的有效点。时间模糊了这些内存线。当然，如果它很重要，我们可以记住这个电话，但是“没有汉堡”的电话，例如将老人放回床上，而不是那么多。我们忘记了对我们的细节及其有责任的人，以确保我们拥有最有可能以电子格式写作的记忆。
Your documented events can be used to refresh your memory during a deposition or while testifying in court. Your documented recall memory is also used in an affirmative defense, indicating that you did everything right for the patient or during the alarm, following protocol, procedures or state law. Your recall memory can also include photographs, electronic videos, and voice recordings.
谁读了你的著作？Everyone starting with your boss, elected officials, the media, the police, certainly attorneys on both sides of the issue, and sometimes the prosecuting attorney if this is a criminal case.
您的文档必须完整，以包括适当的句子结构，单词使用和适当的缩写。总的来说，我们遵循已批准的格式，该格式已经在我们的业务中经过多年的制度化。我们在紧急医疗服务中使用的格式遵循肥皂格式，该格式代表主观，客观，评估和计划。这Subjectivepart is essentially what the patient tells you, including all medical history, medications, and the purpose of the call. The客观的组成部分是您看到的，您的感受和记录的内容，例如血压，出血，伤害，心脏骤停，呼吸窘迫以及这些客观发现。跟随这些是评估, which is crucial as it determines the kind of treatment you will provide to the patient. Finally, is thePlan. We are not trained to be diagnosticians, but our training and experience lead to a conclusion that you would use for the Plan section, which is the treatment provided to the patient. Then document the interactions of improvement, no improvement or whatever occurs after a treatment is provided.
请大声阅读您的叙述before pushing the save button. Reading your documentation out loud may reveals a lot of errors, especially in medical terminology, your intent, and ultimately the outcome of good patient care. Documentation should represent the facts of the issue and not your opinion of what you think the problem is. Stating facts will help you and the outcome if you become sued or are part of litigation related to your patient care.
这essentials of documenting medical care mean you are not writing a novel but reporting the critical issues during your short time with your patient. The ultimate point is, did you write enough to avoid reliance on your memory when the case comes to trial? Remember, if you write something in the document, such as an opinion or hearsay, it will harm you or your department in your defense during a litigation experience.
您正在编写一份报告供其他人阅读。确保信息完成，描述投诉和相关问题，并根据您的协议列出所有考试和治疗。我们倾向于记录更多关键的呼叫，但没有在小型或常见的传单呼叫上记录很多。例如，大的MCI或严重的创伤呼叫，而不是落在地板上的疗养院中的患者。我们认为，大型MCI或射击会导致很多诉讼，并且可能没有诉讼，因此将疗养院的患者捡起并将其放回床上。根据我的经验，由于患者的潜在忽视，我们从疗养院打电话中获得了更多诉讼。从与患者的短暂互动中，而是从将患者放在地板上的一系列事件中来看。您是否检查过头部或骨盆损伤，或者只是将患者捡起，将它们放回床上，然后让现场缺少骨盆骨折或硬膜外血肿。这里的结论是，我们的考试不佳，我们提供了糟糕的服务。
Good writing is a difficult skill, and many of us have found taking shortcuts in a method of communication, especially in the written word, has been damaged by the increased use of technology. For example, many of us will Tweet using 280 characters to convey a message between ourselves, our family, and our friends. There appears to be less use of reference materials such as books, magazine articles, and other available materials. We tend to Google a lot of what we need to make a decision. Even in law school, where books used to be the norm, technology is taking over our ability to research and we get used obtaining our information from Lexis/Nexus and other research sites and less use of the law school library.
这个technology has resulted in the loss of creative thinking or loss of ability to think through a problem. With Fire, Rescue and EMS events, critical thinking is an essential component of our job. I believe although we have the technology available; we have lost the ability to think through a problem. Instead, we “Google it.”
对于我们处理的许多直接问题，我们不能花些时间使用这些资源，因为这些材料都需要像肌肉记忆或称为您大脑的巨型计算机一样容易获得。例如，如果您是消防车上的工程师，并且必须能够计算泵压力，则需要立即可用。如果您是心脏骤停的护理人员，则需要立即能够计算静脉注射率，尤其是在涉及多种药物的情况下。
您的文档必须实时创建，这意味着在通话完成后立即将病人放在医院或医生的办公室，或者在家中以及下一次事件发生之前。最肯定的是，完成文档必须在任何一段时间内休息之前完成。大多数部门都制定了一些政策，这决定了创建这些事件报告的时间。事实之后，请勿尝试创建文件，尤其是如果您在前患者起诉您的部门时收到传票和投诉。俗话说：“如果没有写下来，那就没有发生。”请记住，您的记忆是容易犯错的，直到三年法定时期的医疗事故，才会发生许多诉讼。
When a fire event concludes, additional information is generally compiled from other responding apparatus or agencies and that my take several days for the complete report to be prepared. Ensure that you document your observations on location, especially during a response to potential crime scenes, arson fires, and assist the investigators and putting into detail vital information that may lead to a successful prosecution.
所有完成的意见书必须由目前正在转移并已被指定为某人或有能力这样做的组织成员进行审查。这可能是轮班营负责人，也可能是MSO在轮班结束时审查所有文件。
所有文档都应反映您独立发现中的事实。不要记录其他个人意见或传闻。您也许可以举报平民声明，这些声明可能会在法庭上扔掉；这将有助于您在沉积，询问或试用期间的回忆记忆。
Restraints used- 对于EMS呼叫，必须记录任何限制因素的使用，无论是物理还是化学，任何独特的位置和此类四点约束，以及在患者护理期间可能发生任何设备故障。最好尽早披露信息，而不是在沉积或试验期间发现。鉴于科罗拉多州奥罗拉（Aurora）发生的问题，当护理人员使用一种名为Elijah McLean的患者使用药物以利亚·麦克莱恩（Elijah McLean）使用药物，他死于警察的限制和过量服用，因此，使用化学约束的文献是必不可少的。护理人员的药物。
每个患者都记录下来？- 不断出现的问题是，我必须记录我们看到的每个患者吗？加利福尼亚有两个重要的案例。第一种情况是赖特诉洛杉矶市219 Cal。应用程序。3d 318（1990） - 行为义务。EMS发现一名患者在袭击后躺在地上，控制警察有责任进行检查足以确定患者是否患有疾病或受伤。未能进行此检查可能会导致死亡或严重伤害，并且是严重的疏忽。赖特（Wright）不久后因镰状细胞危机去世。发现护理人员有责任，原告被授予数百万。
这second case isZepeda v. City of Los Angeles223大卡。应用。3 d 232(1990)。一个拍摄场景是unsecured; paramedics waited for the police, Zepeda died. Once EMS begins examination and treatment, a duty of reasonable care is owed. The court stated – No “special duty” to provide aid. They received the call, responded quickly, and were prepared to manage the call so long as the scene was safe. There is no duty of care to a victim until EMS undertakes examination and treatment.
这short story is medical documentation is a legal record that preserves and transmits information and defines your professional credibility. Your documentation will be used in civil and criminal litigation, and refusals must be obtained and well-documented.
Social Media:不要在社交媒体上发布EMS要求进行任何患者互动的要求，因为许多提供者由于判断错误而失业。一些州使EMS提供商张贴有关其患者的图片或信息的犯罪。
拒绝：Patients can refuse care even though it appears evident that care is necessary. A good acronym for refusal issues is CASE CLOSED for your interaction with the patient. Always document refusals carefully, and the goal of the refusal documentation is the limit your liability.
C= Condition, Capacity, and Competence
A= Assessment
S =语句。
E =教育。
C =后果。
L = EMS的局限性。
O= Offer Transport.
S =签名。
E =教育材料。
D= Dial 9-1-1.
有一些简单的规则管理病人to refuse care. Most EMS Systems and protocols would indicate that the patient understands what you’re telling them is contained in the refusal document. The patient must be oriented to person, place, and time and not show any obvious cognitive defects. They must be free of the influence of alcohol and drugs or any mind-altering substances nor have any injury or medical condition that affects their judgment.
A patient must not have expressed an intent to suicide during the episode related to the call you are currently on. The patient must demonstrate the ability to explain the decision back to you that they are making and any possible adverse outcomes, including death or devastating injury.
Refusals must be in writing and signed by the patient or guardian or responsible person managing the patient there, and there should be a witness to the report of any agreement the patient has made to refuse care. As a provider, you must read the refusal document to the patient, assess the patient’s capability or capacity to refuse care, and document that capacity in your narrative. You also must consider the patient’s competency, defined as sufficient understanding and memory to comprehend the current situation, and understand the consequences of their proposed actions, as these are usually legal decisions made in a court of law. However, you’re making the decisions in the field.
明显的死亡：Your documentation must indicate all signs of this event, including time down, EKG findings, patient color, temperature, and any witness statements and possible cause of death, for example, trauma. This is especially important when you’re responding to a patient and their family members are present and watching your every move. It is essential to be accurate detailing the aspects of the obvious death.
记录保留和发布：Retention of records is a policy created by your State and department. The department must follow those retention guidelines and follow the records destruction schedule as outlined in those records retention laws. Paper documents must be shredded to protect patient information and even your own employees’ protected information. Electronic records have their related method of destruction outlined in policy and the law. DO NOT place records to be destroyed in a dumpster.
确保您的部门有一项记录发布政策，该政策允许传票合法访问您的文件，以便由律师甚至警察局发行的记录发布。如果您是帐单实体，则计费机构必须有一封业务伙伴信，允许帐单实体收到有关患者的受保护的健康信息。
Remember HIPAA ((Health Insurance Portability & Accountability Act (www.hhs.gov））在您的指南中发布了保护患者信息的信息。另外，请记住未受保护的环境中的病历可能违反HIPAA或您的州患者隐私法。您和您的组织必须控制对文档的访问。
Electronic Medical Records:Although EMRs are integrally related to improving patient safety, adopting EMRs may raise new risks of malpractice liability through data loss or destruction, inappropriate corrections to the medical record, or inaccurate data entry. There are recorded events of unauthorized access, and errors related to problems during the transition to EHRs are potential liability issues.
Storage:When storing electronic files, ensure your IT department has adequate storage in the cloud or some remote server with a robust firewall. These tools are in place to prevent a hacking or ransomware event from affecting your organization. Paper documents must be stored in a dry and secure space.
Click the Box or Narrative– Which is better? Narratives are your substituted memory describing the actual patient condition in real-time. Clicking the box and writing a narrative is imperative to complete medical documentation. Many of the cases which appear to be “routine” on the surface are the ones that will “get” you. In the EMR, there is space for supplemental narratives if you need to add additional documentation for an event involving a crime, assault on the provider, or any abuse reported, such as a child or elder abuse which are essential in pursuing criminal action.
Modifying the medical document:这re is a misconception that we cannot touch the record after it has been done, which is not valid. There is no reason to change the original narrative in your report, and if you intend to do so, it questions the entire document. There’s always the opportunity to access the documents to make additions to the document, which are generally date stamped and timed. Ensure there is a single point of access available in your organization if the provider needs to add medical information to the document. Do not allow unlimited access to these reports by any organization member. Never, ever falsify information in a report, destroy a report or fail to write a report. Never document your opinions, make assumptions or blame another provider.
Spoliation:必须保护您的医疗和其他信息免受作者或其他信息的删除或破坏。在各个州，销售都是一种犯罪，包括病历，心电图，视频录制，任何类型的录音以及与活动有关的手机中的材料。您必须保留相关的证据和医疗信息。
犯罪现场：犯罪现场的文档至关重要，因为您通常是到达现场的第一响应者。您必须精确地描述到达时出现的场景，并描述您在患者治疗和运输过程中可能打扰的所有事物。如果您将设备留在现场，则必须记录他剩下的东西以及我剩下的地方。应注意观察，而不是结论。
Only do and document that you feel comfortable defending in a court of law. The medical record is the only actual proof of the care and treatment provided to the patient. If任何该信息的输入错误会使整个文档受到质疑，您的文档讲述了患者在您护理中的时间的故事。
In almost 100% of the cases, the outcome of investigations and court cases resolved in your favor directly result from the quality of your documentation.
作为继续培训的一部分，以您的文档技能为一部分，以讲述患者的医疗故事并防止诉讼。
JOHN K. MURPHY, J.D. M.S, PA-C, EFO, began his fire service career as a firefighter/paramedic and retired as a deputy chief after 32 years of service. He is an attorney licensed in Washington whose focus is on firefighter health and safety, firefighter risk management, employment practices liability, employment policy, internal investigations, and expert witness and litigation support. He was a Navy corpsman with the Marine Corps. He is a lecturer, an educator, an author, a legal columnist, a blogger, and a member of Fire Engineering’s Fire Service Court Blog Talk Radio Show. He is also a lecturer at the IAFC Fire Rescue International and I-Women conferences. He is a National Fire Academy instructor. He is a distance learning instructor for the University of Florida Fire and Emergency Services programs.
这个168博金宝 反映作者的观点，不一定是188金宝搏是正规吗.
