Write It Right: Defensible EMS Documentation Copyright 2007, Page Wolfberg & Wirth, LLC.

Write It Right:Write It Right:

Defensible EMS Defensible EMS DocumentationDocumentation

Copyright 2007, Page Wolfberg & Wirth, LLC

© Copyright 2007 Page, Wolfberg & Wirth, LLC© Copyright 2007 Page, Wolfberg & Wirth, LLCAll Rights ReservedAll Rights Reserved

OverviewOverview Part IPart I Basic FrameworkBasic Framework

The Legal System and The Legal System and Avoiding Negligence Avoiding Negligence Claims Claims


OverviewOverview Part II Part II Documentation Documentation

FundamentalsFundamentals

Clinical and Operational Clinical and Operational EssentialsEssentials


OverviewOverview Part IIIPart III Special Situations Special Situations

Consent, Refusals, Consent, Refusals, Minors, Minors, Advance Advance

Directives, and Directives, and Protecting Protecting

Patient PrivacyPatient Privacy

Part IPart I

Basic Framework:Basic Framework:The Legal System and The Legal System and

Avoiding Negligence ClaimsAvoiding Negligence Claims


Part I – OverviewPart I – Overview

Criminal and civil lawCriminal and civil law

Key areas of EMS liabilityKey areas of EMS liability

Defining negligenceDefining negligence


Part I – OverviewPart I – Overview

The case of “negligent The case of “negligent documentation”documentation”

Documentation and the Documentation and the anatomy of a lawsuitanatomy of a lawsuit


The Legal SystemThe Legal System

Criminal Law Criminal Law

Civil LawCivil Law



Criminal Actions in EMSCriminal Actions in EMS

• Vehicle operationsVehicle operations• Health care fraud and abuseHealth care fraud and abuse• EmbezzlementEmbezzlement• Patient abusePatient abuse• DrugsDrugs



Civil Actions in EMSCivil Actions in EMS•NegligenceNegligence•DiscriminationDiscrimination•False Claims False Claims



Tort LawTort Law•Unintentional tortsUnintentional torts•Intentional tortsIntentional torts


Intentional TortsIntentional Torts False imprisonmentFalse imprisonment AssaultAssault BatteryBattery Invasion of privacyInvasion of privacy


Key Areas of EMS LiabilityKey Areas of EMS Liability

Motor Vehicle Accidents Motor Vehicle Accidents

Response DelaysResponse Delays


Key Areas of EMS LiabilityKey Areas of EMS Liability

Bad Refusals (Abandonment)Bad Refusals (Abandonment)•Failure to consider Failure to consider

“competency”“competency”•Failure to document Failure to document


Key Areas of LiabilityKey Areas of Liability

Patient Care IssuesPatient Care Issues•Airway management issuesAirway management issues•Spinal immobilization issuesSpinal immobilization issues•Equipment failures or Equipment failures or

inadequate equipmentinadequate equipment

Poor Documentation Poor Documentation = Potential Liability= Potential Liability

EMS “Malpractice” EMS “Malpractice” Defining NegligenceDefining Negligence


Ordinary NegligenceOrdinary Negligence

““The failure to act as a The failure to act as a reasonably prudent EMT or reasonably prudent EMT or paramedic would act under paramedic would act under similar circumstances”similar circumstances”


Gross NegligenceGross Negligence

““Qualified Immunity” Qualified Immunity”

Similar to “Good Samaritan” Similar to “Good Samaritan” laws: Immunity may only laws: Immunity may only apply to individual care apply to individual care providerprovider



Substantially moreSubstantially more than than “ordinary carelessness, “ordinary carelessness, inadvertence, laxity or inadvertence, laxity or indifference”indifference”



Behavior that is “Behavior that is “flagrant, flagrant, grossly deviating from the grossly deviating from the ordinary standard of careordinary standard of care””


Elements of NegligenceElements of Negligence

DutyDuty BreachBreach DamagesDamages Proximate Cause Proximate Cause


Duty to ActDuty to Act

Legal duty vs. moral dutyLegal duty vs. moral duty


Breach of DutyBreach of Duty

Failure to uphold Failure to uphold standard of standard of carecare

Failure to act as a “reasonably Failure to act as a “reasonably prudent provider would under prudent provider would under similar circumstances”similar circumstances”


Breach of DutyBreach of Duty

Expert witnessesExpert witnesses


Damages (Harm)Damages (Harm)

Medical expensesMedical expenses Pain and sufferingPain and suffering Lost wagesLost wages Funeral expensesFuneral expenses Punitive damagesPunitive damages


Proximate CauseProximate Cause

Did your negligence Did your negligence causecause the the harm to the patient?harm to the patient?

Courts often look at Courts often look at “foreseeability”“foreseeability”• Was the harm a “foreseeable Was the harm a “foreseeable

consequence” of your conduct?consequence” of your conduct?


Organizations Are Organizations Are Liable Liable

For the Conduct of For the Conduct of Their “Agents”Their “Agents”

Case Study:Case Study:The Case of Negligent The Case of Negligent

DocumentationDocumentation


The Case of The Case of “Negligent Documentation”“Negligent Documentation”

De Tarquino v. The City of Jersey De Tarquino v. The City of Jersey CityCity (Superior Court of New (Superior Court of New Jersey, Appellate Division, 2002)Jersey, Appellate Division, 2002)


FactsFacts

Patient allegedly involved in Patient allegedly involved in altercation with policealtercation with police

EMTs arrived at the police station EMTs arrived at the police station Patient vomited during the EMS Patient vomited during the EMS

treatmenttreatment


Alleged FactsAlleged Facts

Transported patient Transported patient Crew provided copy of PCR to Crew provided copy of PCR to

the hospitalthe hospital PCR indicated “-N/V” PCR indicated “-N/V”

(negative for (negative for nausea/vomiting)nausea/vomiting)


Alleged Facts Alleged Facts

Hospital released patient to Hospital released patient to police police

Experienced seizures Experienced seizures Transported again Transported again Declared brain dead: Epidural Declared brain dead: Epidural

hematomahematoma


The LawsuitThe Lawsuit

Family alleged that Family alleged that ambulance crew negligently ambulance crew negligently failed to document that the failed to document that the patient vomitedpatient vomited


The LawsuitThe Lawsuit

Trial court:Trial court:• Dismissed the lawsuit against the Dismissed the lawsuit against the

EMTsEMTs• NJ immunity statute protected NJ immunity statute protected

them from liabilitythem from liability


The IssueThe Issue

Does the immunity provision Does the immunity provision apply only to the direct rendering apply only to the direct rendering of patient care, or does it include of patient care, or does it include the preparation of the preparation of documentation describing that documentation describing that care?care?


Appeals Court DecisionAppeals Court Decision

Plaintiff’s claim not based on Plaintiff’s claim not based on negligence in the negligence in the performanceperformance of of actual patient careactual patient care

Claim based on alleged Claim based on alleged negligence in negligence in failing to properly failing to properly documentdocument that care that care


Appeals Court DecisionAppeals Court Decision

Immunity statute did NOT Immunity statute did NOT protect against negligence in protect against negligence in documentation documentation


Lessons From This CaseLessons From This Case

Documentation may be Documentation may be “negligent” even when patient “negligent” even when patient care is notcare is not

Standard of “ordinary Standard of “ordinary negligence” may apply to negligence” may apply to documentation rather than documentation rather than “gross negligence”“gross negligence”


Lessons From This CaseLessons From This Case

Immunity statutes can’t be Immunity statutes can’t be relied on to protect you in all relied on to protect you in all cases!cases!


The PCR in CourtThe PCR in Court

Discovery before the lawsuit is Discovery before the lawsuit is filed filed

During discovery During discovery During trial while YOU are on the During trial while YOU are on the

witness stand!witness stand!

Part IIPart II

Documentation FundamentalsDocumentation FundamentalsClinical and Operational Clinical and Operational

EssentialsEssentials


Part II - OverviewPart II - Overview

Purposes of EMS Purposes of EMS documentation documentation

Documentation fundamentals Documentation fundamentals


Part II - OverviewPart II - Overview

Chronological documentation Chronological documentation The “C.A.T.” approach The “C.A.T.” approach Making amendmentsMaking amendments


Basic Purposes of Basic Purposes of EMS DocumentationEMS Documentation

Document patient careDocument patient care Quality assuranceQuality assurance Data collectionData collection Legal recordLegal record Reimbursement recordReimbursement record


Key is CommunicationKey is Communication

A well prepared PCR will only A well prepared PCR will only come about when you have a come about when you have a good good rapportrapport and effective and effective communicationscommunications with the with the patient!patient!


““Seeing the Same Patient”Seeing the Same Patient”

Two people should be able to Two people should be able to read a PCR and visualize a read a PCR and visualize a patient with the same level of patient with the same level of acuity acuity


““Visualization Test”Visualization Test”

If another field provider’s vision If another field provider’s vision of the patient after reading the of the patient after reading the PCR is not close to your vision, PCR is not close to your vision, check your documentation!check your documentation!


Documentation Documentation FundamentalsFundamentals


FUNDAMENTAL PRINCIPLEFUNDAMENTAL PRINCIPLE::

Watch Abbreviations, Spelling Watch Abbreviations, Spelling and Acronyms!and Acronyms!

Neatness and Organization Neatness and Organization DO COUNT!DO COUNT!


Abbreviations and AcronymsAbbreviations and Acronyms

Maximize information you can Maximize information you can document document


Abbreviations and AcronymsAbbreviations and Acronyms

StandardStandard and and approvedapproved abbreviations and acronyms abbreviations and acronyms ONLY! ONLY!


““If It Isn’t Written, It If It Isn’t Written, It Didn’t Happen!”Didn’t Happen!”


Need to Document . . .Need to Document . . .

RRelevant historyelevant history Pertinent findingsPertinent findings Pertinent negativesPertinent negatives Relevant actions takenRelevant actions taken


General General Documentation FormatDocumentation Format


Documentation FormatDocumentation Format

S. O. A. P.S. O. A. P.

C. H. A. R. T.C. H. A. R. T.


S. O. A. P.S. O. A. P.

S S ubjective ubjective O O bjective bjective A A ssessment ssessment P P lanlan


C. H. A. R. T.C. H. A. R. T.

CC hief Complaint hief Complaint HH istory istory AA ssessment ssessment RRx (treatment) x (treatment) TT ransport ransport


C C hief Complainthief Complaint

UsuallyUsually what the patient tells what the patient tells you (but not always!) you (but not always!)

““Patient’s chief complaint is Patient’s chief complaint is chest pain”chest pain”


H H istoryistory

History of present illnessHistory of present illness•Elaborates on chief complaintElaborates on chief complaint•Described by patient or othersDescribed by patient or others•Answers the question: What Answers the question: What

happened?happened?


H H istoryistory

Past medical historyPast medical history•Relevant past medical Relevant past medical

conditions conditions


H H istoryistory

MedicationsMedications•Current medications and Current medications and

dosage dosage Allergies to medicationsAllergies to medications


AA ssessment ssessment

General impression of the General impression of the patient patient



Level of consciousness Level of consciousness Vital signsVital signs



Field diagnostic tests Field diagnostic tests Head-to-toe physical examHead-to-toe physical exam


RRx - Treatmentx - Treatment

Standing orders or protocols Standing orders or protocols Medical command Medical command Interventions Interventions Patient responsePatient response


TT ransport ransport

Method of transfer (stair chair to Method of transfer (stair chair to stretcher, etc.) stretcher, etc.)


TT ransport ransport

Mode of transportation Mode of transportation (ambulance)(ambulance)

Condition enroute, additional Condition enroute, additional treatment and responsetreatment and response

Transfer of care to hospital staffTransfer of care to hospital staff


Documentation FormatsDocumentation Formats

These are suggested approachesThese are suggested approaches Comply with your agency’s Comply with your agency’s

policies policies


Documentation FundamentalsDocumentation Fundamentals

Avoid Avoid subjectivesubjective statements statements and conclusions! and conclusions!



Use Use quotationsquotations and and paraphrasingparaphrasing appropriately appropriately


Patient describes pain as Patient describes pain as “crushing like a boulder on “crushing like a boulder on my chest”my chest”


Patient states “I had about 6 Patient states “I had about 6 beers before I left the tavern”beers before I left the tavern”



Observation of the first Observation of the first responders/bystandersresponders/bystanders

Vital signs/assessmentsVital signs/assessments Patient’s mental status Patient’s mental status

(consent)(consent)



Command consult, orders and Command consult, orders and adherence to protocoladherence to protocol



Transfer of care and condition Transfer of care and condition at time of transferat time of transfer


Documenting Documenting InterventionsInterventions


Intravenous LinesIntravenous Lines

Where started Where started Who started itWho started it Size and type of catheterSize and type of catheter Type of fluidType of fluid Infusion rateInfusion rate Patient responsePatient response


OxygenOxygen

Who administered itWho administered it Device usedDevice used Flow rateFlow rate Pre- and post- saturation Pre- and post- saturation

levelslevels Patient responsePatient response


MedicationsMedications

Contraindications and allergiesContraindications and allergies Name of medicationName of medication Dosage, method and route of Dosage, method and route of

administrationadministration Time administeredTime administered Who administered itWho administered it Patient responsePatient response


Documentation of Documentation of Access DelaysAccess Delays

Causes of delays in Causes of delays in accessing or transporting accessing or transporting the patientthe patient


Documentation of Documentation of Access DelaysAccess Delays

ExtricationExtrication WeatherWeather TrafficTraffic CrowdsCrowds Hazardous materialsHazardous materials Violent/unsafe sceneViolent/unsafe scene


Chronological DocumentationChronological Documentation

How was patient moved? (two-How was patient moved? (two-person sheet lift, standing pivot, person sheet lift, standing pivot, walked to stretcher, “shuffled 5 walked to stretcher, “shuffled 5 feet with assistance on each side feet with assistance on each side to the stretcher”)to the stretcher”)


How Was Patient Moved?How Was Patient Moved?

Two-person sheet liftTwo-person sheet lift Standing pivotStanding pivot Walked to stretcherWalked to stretcher

• Unassisted?Unassisted?• Assistance required?Assistance required?• Was gait steady or unsteady?Was gait steady or unsteady?


Chronological DocumentationChronological Documentation

Disposition of patient? Disposition of patient? (transported, refused care (transported, refused care and transport, etc.)and transport, etc.)


CComplete and omplete and AAccurate ccurate and and TTimely imely (“C.A.T.”) (“C.A.T.”)

Patient Care Report Patient Care Report CompletionCompletion


The “CAT” Approach!The “CAT” Approach!

CompleteComplete•All sections completedAll sections completed•All important questions All important questions

answered answered •All necessary signatures All necessary signatures

obtained obtained


The “CAT” ApproachThe “CAT” Approach

AccurateAccurate•Information documented is Information documented is

correct correct •No typos or other plain errorsNo typos or other plain errors•Legible!Legible!•Correct internal procedures Correct internal procedures

followedfollowed


The “CAT” ApproachThe “CAT” Approach

TimelyTimely•Provide to ER and others Provide to ER and others

according to standardaccording to standard•Complete BEFORE end of shift Complete BEFORE end of shift

or according to standardor according to standard


Internal ConsistencyInternal Consistency

PCR should not “contradict itself”PCR should not “contradict itself” Read it!Read it! Ensure internal consistency Ensure internal consistency

between:between:• Different sectionsDifferent sections• Different crew membersDifferent crew members


““Changing the Chart”Changing the Chart”

Misconception: “We can’t Misconception: “We can’t touch the report after it’s touch the report after it’s done”done”

Reality: Late entries and Reality: Late entries and corrections are permissiblecorrections are permissible



Appropriately noted and datedAppropriately noted and dated

Should not represent change as Should not represent change as if it was an original entryif it was an original entry

Addendums if clearly dated and Addendums if clearly dated and markedmarked

Original authorOriginal author



Paper forms: Correct errors Paper forms: Correct errors with strikeout lines, initials and with strikeout lines, initials and date – (No “white-out”)date – (No “white-out”)

Supplemental sheets Supplemental sheets permissiblepermissible



Proper Proper and and improper improper reasons to reasons to “change” your documentation!“change” your documentation!• Proper: To correct errors, oversights, Proper: To correct errors, oversights,

omissions, etc.omissions, etc.• Improper: To falsify, misrepresent, or Improper: To falsify, misrepresent, or

cover up cover up


Documentation Documentation ExampleExample


DispatchDispatch

““Dispatched by 911 and Dispatched by 911 and responded immediately to responded immediately to possible heart attack. Upon possible heart attack. Upon arrival found an appx. 300 lb. arrival found an appx. 300 lb. male lying back on recliner in male lying back on recliner in living room, ashen, diaphoretic, living room, ashen, diaphoretic, and in acute distress”and in acute distress”


Chief ComplaintChief Complaint

““Chest Pain”Chest Pain”


History of Present IllnessHistory of Present Illness

““Patient states pain began about Patient states pain began about an hour ago centered an hour ago centered substernally and that it has substernally and that it has remained constant. States he remained constant. States he was watching TV when pain was watching TV when pain began.”began.”


History of Present IllnessHistory of Present Illness

““He describes pain as ‘crushing’ He describes pain as ‘crushing’ and ‘very bad’ at 9 intensity on 1-and ‘very bad’ at 9 intensity on 1-10 scale. States pain radiates 10 scale. States pain radiates down his left arm which feels down his left arm which feels “dull.” Patient also has nausea but “dull.” Patient also has nausea but has not vomited. Denies shortness has not vomited. Denies shortness of breath and has no other pain or of breath and has no other pain or complaints.”complaints.”


Past Medical HistoryPast Medical History

““Patient had a heart attack in Patient had a heart attack in 2000. States he had three stents 2000. States he had three stents inserted in 2001.”inserted in 2001.”


Meds and AllergiesMeds and Allergies

““NKA. Patient takes no NKA. Patient takes no prescription meds, takes 1 - 82 prescription meds, takes 1 - 82 mg aspirin tablet daily.”mg aspirin tablet daily.”


Physical Assessment Physical Assessment

““Assessment performed by Assessment performed by Paramedic Waylon Yelp. Paramedic Waylon Yelp. Patient alert and oriented x 4 but Patient alert and oriented x 4 but in acute distress from the pain, in acute distress from the pain, GCS 15, skin diaphoretic ashen GCS 15, skin diaphoretic ashen in color.”in color.”


Physical Assessment Physical Assessment

““Monitor shows Sinus Tach at Monitor shows Sinus Tach at 120. O2 sat 90%. Lungs were 120. O2 sat 90%. Lungs were clear bilaterally all fields, clear bilaterally all fields, abdomen soft non-tender. Able abdomen soft non-tender. Able to move all extremities with to move all extremities with equal strength and sensation.” equal strength and sensation.”


Treatment Treatment

““Patient placed on O2 at 15 lpm Patient placed on O2 at 15 lpm non-rebreather mask. 12 lead non-rebreather mask. 12 lead EKG shows ST elevation in Leads EKG shows ST elevation in Leads 2 and 3 w/sinus tachycardia. IV 2 and 3 w/sinus tachycardia. IV established 16 ga. left AC area. established 16 ga. left AC area. Running TKO with normal saline Running TKO with normal saline solution.”solution.”


TreatmentTreatment

““Medical command ordered MS 2 Medical command ordered MS 2 mg IV slowly and gave mg IV slowly and gave permission to give up to 8 mg permission to give up to 8 mg titrated for pain relief. Also titrated for pain relief. Also ordered to give 2 aspirin tablets ordered to give 2 aspirin tablets and transport immediately.”and transport immediately.”


TreatmentTreatment

““Administered aspirin PO. Administered aspirin PO. Patient was transferred from Patient was transferred from recliner to stretcher using a two recliner to stretcher using a two person seat lift. Kept in Fowler’s person seat lift. Kept in Fowler’s position. Moved to ambulance position. Moved to ambulance and transported to ABC Hospital and transported to ABC Hospital ED.”ED.”


Transport and DispositionTransport and Disposition

““While enroute, administered While enroute, administered additional 2 mg MS IV slowly and additional 2 mg MS IV slowly and within a minute patient states the within a minute patient states the pain has decreased somewhat pain has decreased somewhat from a 9 to a 5. No other change from a 9 to a 5. No other change in patient condition except his in patient condition except his color has improved and he is less color has improved and he is less diaphoretic.”diaphoretic.”


Transport and DispositionTransport and Disposition

““No other complaints while No other complaints while enroute. Upon arrival at hospital, enroute. Upon arrival at hospital, transferred patient from stretcher transferred patient from stretcher to ED litter using four person sheet to ED litter using four person sheet lift and continued Fowler’s lift and continued Fowler’s position. Care transferred to Sally position. Care transferred to Sally Sick, RN.”Sick, RN.”

Part IIIPart III

Special Situations Special Situations Consent, Refusals, Minors, Consent, Refusals, Minors,

Advanced Directives, and Protecting Advanced Directives, and Protecting Patient PrivacyPatient Privacy


Part III - OverviewPart III - Overview

Importance of obtaining Importance of obtaining “informed consent”“informed consent”

Assessing legal and mental Assessing legal and mental capacitycapacity

Handling and documenting Handling and documenting “refusals”“refusals”


Part III - OverviewPart III - Overview

Defining who is a patientDefining who is a patient ““Do Not Resuscitate” Do Not Resuscitate”

documentationdocumentation Patient privacy and Patient privacy and

confidentiality confidentiality


Properly Obtaining Properly Obtaining Informed Consent Informed Consent

for Treatmentfor Treatment


Consent ChallengesConsent Challenges

Minor patientsMinor patients Mental patientsMental patients ““Walking Wounded”Walking Wounded”


Consent ChallengesConsent Challenges

““No patient found”No patient found” ElderlyElderly Obviously in need of medical Obviously in need of medical

carecare


Consent:Consent:

Informed authorization given by a Informed authorization given by a patient, who is both mentally and patient, who is both mentally and legally competent, to emergency legally competent, to emergency

medical services personnel for the medical services personnel for the provision of medical care and/or provision of medical care and/or

transportationtransportation


The Goal: The Goal: InformedInformed Consent Consent


Patient must be INFORMED of Patient must be INFORMED of the RISKS of refusing care and the RISKS of refusing care and

the BENEFITS of treatmentthe BENEFITS of treatment


Legal CapacityLegal Capacity

MinorityMinority• Under the age of 18Under the age of 18• State laws typically contain some State laws typically contain some

exceptionsexceptions Adjudication of incapacityAdjudication of incapacity


Mental CapacityMental Capacity

Organic brain diseaseOrganic brain disease• Alzheimers or senile dementiaAlzheimers or senile dementia

Situational medical crisesSituational medical crises• HypoxiaHypoxia• HypoglycemiaHypoglycemia• Head traumaHead trauma

IntoxicationIntoxication


Mental CapacityMental Capacity

Assumption that patients are Assumption that patients are competent until proven competent until proven otherwiseotherwise


Field Assessment of Field Assessment of Mental CapacityMental Capacity

Provider judgment based on Provider judgment based on training, experience, training, experience, assessment, etc.assessment, etc.


Field Assessment of Field Assessment of Mental CapacityMental Capacity

Alert and OrientedAlert and Oriented• PersonPerson• PlacePlace• TimeTime• SituationSituation


Glasgow Coma ScoreGlasgow Coma Score

Helpful adjunct for assessment of Helpful adjunct for assessment of mental competencymental competency

Helpful for documenting competencyHelpful for documenting competency


Assessing Competence Assessing Competence

No absolute or “bright line” tests No absolute or “bright line” tests for mental competencyfor mental competency

Document your findings Document your findings accordingly!accordingly!


Informed Consent = KnowledgeInformed Consent = Knowledge

Enough information that a Enough information that a “reasonable person” would find “reasonable person” would find necessary and relevant to necessary and relevant to medical decision-makingmedical decision-making


Express ConsentExpress Consent

Verbal Verbal PhysicalPhysical


Implied ConsentImplied Consent

Exception to informed Exception to informed consent doctrineconsent doctrine

Recognized in all statesRecognized in all states


Implied ConsentImplied Consent

Harm of failure to treat Harm of failure to treat outweighsoutweighs the harm from the harm from proposed treatmentproposed treatment

Impractical to obtain consentImpractical to obtain consent


Involuntary ConsentInvoluntary Consent

Laws that permit temporary Laws that permit temporary treatment or confinementtreatment or confinement

Harm to self or othersHarm to self or others


Scope of ConsentScope of Consent

Limitations on treatment or Limitations on treatment or transporttransport

Obtain patient’s signatureObtain patient’s signature Withdrawal of consentWithdrawal of consent

Patient Refusals


Basic RuleBasic Rule::

A properly informed patient who is A properly informed patient who is both legally and mentally both legally and mentally

competent has a right to refuse any competent has a right to refuse any and all medical care, even if that and all medical care, even if that medical care would save his lifemedical care would save his life


Refusal AssessmentsRefusal Assessments

Perform Perform three three assessments:assessments:•LegalLegal competence competence•MentalMental competence competence•SituationalSituational or medical or medical

competencecompetence


Like informed Like informed consentconsent, , informed informed refusalrefusal should should

be the goal!be the goal!


Informed RefusalsInformed Refusals

A refusal situation is more A refusal situation is more legally defensible when it is legally defensible when it is “knowing” and “informed”“knowing” and “informed”


Informed RefusalsInformed Refusals

Patient or legal decision-maker Patient or legal decision-maker must be informed of and must be informed of and understand:understand:• Risks of non-treatment/non-transportRisks of non-treatment/non-transport• Benefits of treatment/transportBenefits of treatment/transport• Options and alternativesOptions and alternatives


Legal DecisionmakerLegal Decisionmaker

For refusal purposes, same as for For refusal purposes, same as for consent purposesconsent purposes• PatientPatient• Legal guardianLegal guardian• Power of Attorney (POA)Power of Attorney (POA)• School officialsSchool officials


Documenting RefusalsDocumenting Refusals

Complete patient assessmentComplete patient assessment Patient’s mental statusPatient’s mental status Discussion with patientDiscussion with patient Refusal/release formRefusal/release form


Documenting RefusalsDocumenting Refusals

Discussion of risksDiscussion of risks Patient’s refusal Patient’s refusal Consult with Medical CommandConsult with Medical Command Obtain patient/witness signatureObtain patient/witness signature


The “A3 E3 P3”The “A3 E3 P3”ApproachApproach


A3A3 AssessAssess - patient condition and - patient condition and

capacity to make decisionscapacity to make decisions



capacity to make decisionscapacity to make decisions AdviseAdvise - patient of his condition - patient of his condition

and proposed treatmentand proposed treatment



capacity to make decisionscapacity to make decisions AdviseAdvise - patient of his condition - patient of his condition

and proposed treatmentand proposed treatment AvoidAvoid - confusing terminology - confusing terminology


E3E3 Ensure Ensure - the refusal is - the refusal is

knowing and voluntaryknowing and voluntary



knowing and voluntaryknowing and voluntary ExploitExploit – uncertainty – uncertainty



knowing and voluntaryknowing and voluntary ExploitExploit – uncertainty – uncertainty ExplainExplain - alternatives - alternatives

(consider a “Medical Miranda” (consider a “Medical Miranda” card)card)


P3P3 PersistPersist - don’t give up easily - don’t give up easily


P3P3 PersistPersist - don’t give up easily - don’t give up easily ProtectProtect - by documentation - by documentation


P3P3 PersistPersist - don’t give up easily - don’t give up easily ProtectProtect - by documentation - by documentation ProtocolsProtocols - comply with - comply with

them or make one that them or make one that works!works!


Example:Example:The Bus Accident – The Bus Accident –

Who is a Patient?Who is a Patient?


““Do we need to obtain refusal Do we need to obtain refusal signatures from each signatures from each

passenger?”passenger?”


Who is a “Patient?”Who is a “Patient?”

Preferable to have refusal Preferable to have refusal signatures signatures

The more refusal signatures you The more refusal signatures you obtain, the more protection you obtain, the more protection you havehave


Who is a “Patient?”Who is a “Patient?”

At a minimum, attempt to At a minimum, attempt to document names/conditions and document names/conditions and refusals on one PCRrefusals on one PCR


““Cancellations”Cancellations”

Document agency which Document agency which canceledcanceled

Document reason for Document reason for cancellationcancellation

Document all relevant timesDocument all relevant times


““Public Service” CallsPublic Service” Calls

Person slipped out of her chair Person slipped out of her chair and requires assistance getting and requires assistance getting back into itback into it

Person needs assistance opening Person needs assistance opening a vial of medicationa vial of medication


Example:Example:The Public Assist CallThe Public Assist Call


Public assist call to help move an Public assist call to help move an elderly female back into her chair at elderly female back into her chair at a private residencea private residence


You report to the residence, enter You report to the residence, enter the house, and find an elderly the house, and find an elderly person, Mrs. Smith, in no apparent person, Mrs. Smith, in no apparent distress, laying on the floor in front distress, laying on the floor in front of a recliner of a recliner


You assist Mrs. Smith from the floor You assist Mrs. Smith from the floor back into her chairback into her chairShe thanks you and you go back to She thanks you and you go back to the station the station


Ten days later, your organization Ten days later, your organization receives a distressed telephone call receives a distressed telephone call from Mrs. Smith’s sonfrom Mrs. Smith’s son


The son informs you that his The son informs you that his mother suffered a fractured hip mother suffered a fractured hip falling from her chair at home, was falling from her chair at home, was taken to the hospital, and passed taken to the hospital, and passed away a week lateraway a week later


The son says that he was told by a The son says that he was told by a neighbor that your EMS agency neighbor that your EMS agency was at his mother’s house 10 days was at his mother’s house 10 days earlierearlier


He is angry that no care was He is angry that no care was provided when his mother provided when his mother obviously suffered so significant an obviously suffered so significant an injuryinjury


You interview the crew and You interview the crew and determine that the patient determine that the patient complained of no pain and was in complained of no pain and was in no distress at the time of your no distress at the time of your public service assistpublic service assist


The family later brings a lawsuit for The family later brings a lawsuit for failing to provide necessary care to failing to provide necessary care to Mrs. SmithMrs. Smith


Because Mrs. Smith was African Because Mrs. Smith was African American, the family also brings American, the family also brings civil rights claims, asserting that civil rights claims, asserting that your organization’s failure to treat your organization’s failure to treat Mrs. Smith was due to her raceMrs. Smith was due to her race


Without contemporaneous Without contemporaneous documentation, any written documentation, any written evidence from this incident evidence from this incident produced after the fact could produced after the fact could appear self-serving and defensiveappear self-serving and defensive


But proper documentation of the But proper documentation of the incident could establish that Mrs. incident could establish that Mrs. Smith was not in pain and Smith was not in pain and complained of no injuries at the complained of no injuries at the time of the public assist calltime of the public assist call


Tiered EMS SystemsTiered EMS Systems

Who documents?Who documents?


Documentation in Tiered Documentation in Tiered EMS SystemsEMS Systems

ALS releases patient to BLS ALS releases patient to BLS How much ALS information How much ALS information

should a BLS provider document?should a BLS provider document?


ALS-BLS Intercepts - ALS-BLS Intercepts - Documentation CaveatsDocumentation Caveats

BLS providers should not BLS providers should not document beyond their scope of document beyond their scope of practicepractice


Advanced Directives and Advanced Directives and “Do Not Resuscitate” “Do Not Resuscitate”

OrdersOrders

““Do Not Resuscitate” Do Not Resuscitate” (DNR) Orders (DNR) Orders

and Advance Directivesand Advance Directives

““The Ultimate Refusal of Care”The Ultimate Refusal of Care”


DNR IssuesDNR Issues

A DNR order typically means you A DNR order typically means you should withhold:should withhold:• Cardiac compressionsCardiac compressions• DefibrillationDefibrillation• IntubationIntubation• Artificial ventilationArtificial ventilation• Administration of resuscitative Administration of resuscitative

drugsdrugs



Does notDoes not mean that pain cannot mean that pain cannot be relieved, or in some cases be relieved, or in some cases other lifesaving efforts (non other lifesaving efforts (non cardiac or resuscitative) can not cardiac or resuscitative) can not be attempted be attempted



Be attentive to:Be attentive to:•Presence of DNRPresence of DNR•ValidityValidity


Advance Directives Advance Directives

““Powers of Attorney” Powers of Attorney” “Advance Directives” or “Advance Directives” or “Living Wills” are often NOT “Living Wills” are often NOT the same as a DNR Orderthe same as a DNR Order


Durable Power of AttorneyDurable Power of Attorney

““Durable Power of Attorney Durable Power of Attorney for Health Care” (DPAHC) – for Health Care” (DPAHC) – Allows a surrogate to make Allows a surrogate to make health care and other health care and other decisions for the patient decisions for the patient


Good Rules to FollowGood Rules to Follow

Err on the side of the patient: Err on the side of the patient: When in doubt, resuscitate!When in doubt, resuscitate!

If DNR Form or bracelet is not If DNR Form or bracelet is not found, resuscitation efforts found, resuscitation efforts should be initiated or continued should be initiated or continued if clinically appropriateif clinically appropriate


DNRDNRDocumentation IssuesDocumentation Issues


DNR: Documentation IssuesDNR: Documentation Issues

Existence and form of DNR orderExistence and form of DNR order Revocation Revocation Questions about validityQuestions about validity Statements of patient/familyStatements of patient/family


Protecting Patient Privacy Protecting Patient Privacy and Confidentialityand Confidentiality


Confidentiality ConcernsConfidentiality Concerns

PCRs are medical recordsPCRs are medical records The agency is the “owner” of The agency is the “owner” of

the recordthe record


Confidentiality ConcernsConfidentiality Concerns

The owner of the record – The owner of the record – the the organization - has a duty to organization - has a duty to protect its confidentialityprotect its confidentiality


State Statutes

AIDS/HIVAIDS/HIV Drug/alcohol treatmentDrug/alcohol treatment Psychiatric Psychiatric


““Protected Health Information” Protected Health Information” (PHI)(PHI)

Verbal Verbal WrittenWritten ElectronicElectronic Photographic/videoPhotographic/video Includes PCRsIncludes PCRs


May Disclose PHI For . . .May Disclose PHI For . . .

TreatmentTreatment Payment Payment Health care operationsHealth care operations


It’s Up to It’s Up to All of UsAll of Us to Make to Make Privacy and Confidentiality Part Privacy and Confidentiality Part of Our Organizational Culture, of Our Organizational Culture,

at at All LevelsAll Levels of the Organization of the Organization


The “Golden Rule” of Patient The “Golden Rule” of Patient Confidentiality: Confidentiality:

What You See HereWhat You See HereWhat You Hear HereWhat You Hear Here

When You Leave HereWhen You Leave HereLet It Stay Here!Let It Stay Here!


Electronic Medical Electronic Medical Records and PCRsRecords and PCRs


Many Advantages of Many Advantages of Electronic PCRsElectronic PCRs

LegibilityLegibility SpellingSpelling OrganizationOrganization Prompts and reminders Prompts and reminders


Standing Up in CourtStanding Up in Court

No major issuesNo major issues Treated like paper Treated like paper

“originals”“originals”

Write It Right: Defensible EMS Documentation Copyright 2007, Page Wolfberg & Wirth, LLC.

Documents

page wolfberg wirth

negligence slide

rights reserved overview

lawsuit slide

document slide

patient privacy slide

potential liability

civil law criminal