This article contains generic information – not legal advice. If you find yourself in a questionable or problematic situation, seek professional legal counsel.

In this series of articles on malpractice liability for premed EMTs, we’ll look at one of the most important and least favorite tasks of many health care providers – documentation. A better understanding of the purposes for documentation will help make this task a priority for the premed EMT. Even if you’re not volunteering as an EMT, you can benefit from improving upon documentation skills prior to medical school.

When I was in law school, one of the most memorable adages law professors drilled into our minds was, “If you didn’t write it down, it didn’t happen!” This detailed attention to properly document events and conversations carried over into my practice of law. It was not uncommon to meet with clients and then spend an hour afterward recording the details of the meeting in a memo. Similarly, documentation in healthcare is a necessary component of competent practice.

A nationwide study by Dr. Steffie Woolhandler and Dr. David Himmelstein in the peer-reviewed International Journal of Health Services analyzed confidential data from the 2008 Health Tracking Physician Survey of a nationally represented sample of 4,720 physicians that practiced at least 20 hours per week. The results were that the average U.S. doctor spends 8.7 hours per week or 16.6% of his or her working time on paperwork. In addition to clinical work, other studies have also pointed out that a significant part of your job as a physician will involve documentation.

Documentation serves to record the clinical care and assessment of patients in their medical record. For premed EMTs, patient care reports (PCRs) will be filled out which include information such as the patient’s signs and symptoms, the EMS assessment of the patient’s condition, and interventions or treatment.

PCRs for pre-hospital care can provide vital information for the continued treatment in the receiving facility. If it’s not possible to provide a completed PCR to the next level provider, any information obtained should still be communicated. An example would be changes in vital signs while en route to the hospital. Note: For premed EMTs, check your local EMS laws and regulations to find out if a full PCR report must be submitted to the hospital within a certain window of time such as 24 hours.

A 2002 New Jersey court’s unpublished opinion in DeTarquino v. the City of New Jersey highlights the importance of documentation for premed EMTs. After an altercation with police officers, DeTarquino vomited during the course of EMS treatment and transport. However, this fact was not documented in the PCR. The hospital that received the young man discharged him and returned him to police custody after an evaluation. While at the police station, DeTarquino suffered a grand mal seizure, was transported to a trauma center, and was later pronounced brain dead from an epidural hematoma.

DeTarquino’s family brought suit alleging, among other things, the ambulance service and the individual EMS providers were negligent in their documentation. The state’s court of appeals agreed with the family’s argument. Had the EMS crew documented that the patient vomited in transport, the initial hospital would probably have considered evaluating DeTarquino for a serious head injury. The appellate court held that the state EMS Act immunity provisions did not protect providers from negligent documentation – only negligent care.

While DeTarquino’s case is only applicable in New Jersey, it is useful in highlighting the importance of accurate and timely recordkeeping and how future courts in other states may view negligent documentation. In addition to patient safety reasons, documentation can serve to support a health care provider’s defense in the event of a malpractice allegation or lawsuit. Overall, the DeTarquino case shows both the clinical and legal importance of thorough and timely documentation.

Documentation (such as in the PCR) also plays a crucial role when it comes to billing and reimbursement for services rendered. For instance, Medicare is the single largest payer for ambulance services. Most EMS organizations receive 30-50% of their revenue from ambulance service charges. However, Medicare will only pay for ambulance services when the patient cannot safely be transported by other means such as a taxi, car, bus, or van. Thus, proper documentation for billing purposes is essential in getting a timely payment.

Like many fellow premed EMTs, I’m applying for membership as a volunteer EMT at a volunteer station house. The issue of paying attention to financial realties and bottom lines cannot be underestimated.

Lastly, keeping proper documentation is simply following the law. Legal and ethical compliance is critical to the integrity of health care providers at an individual and organizational level.

Keep these documentation tips in mind:

  • Write an accurate record of your time with the patient
  • Record the patient’s narrative as well as your clinical impressions
  • Remember to check appropriate boxes and other fill-in sections
  • Make sure your handwriting is legible
  • Assess and document more than one set of vital signs

Always remember: if you don’t write it down, it didn’t happen!

Stay tuned for Erin’s next article

Headshot of Erin FortnerErin Fortner is a licensed attorney in Georgia where she practiced pharmaceutical product liability law and was a special victims unit prosecutor. She lives in the D.C. metro area and is attending a full-time post-baccalaureate program. Ms. Fortner also recently earned her EMT certification.