Today’s correspondent has:

… struggled to conceive of what would be considered sufficient documentation on our patient care records.

I’ve been working as a paramedic for 14 years and yet I still don’t feel like I know what is a minimum standard of paperwork, as a result I fear I often tend to write too much, and err on the side of caution.

I suspect the answer will be ‘it depends on the case’ but I was wondering if you could give a legal perspective on what might constitute both sufficient and insufficient paperwork, should we be unfortunate enough to ‘end up in coroners court’.

At the beginning of our careers we are warned, ‘if you end up in coroners court, your paperwork had better be good’, and ‘if it’s not written down, it didn’t happen’ and various other iterations of what is possibly scaremongering. This mantra is repeated ad nauseum throughout a paramedics’ career, however as paramedics we receive very little training regarding paperwork completion. What training there is, is often just the particular paramedic trainers take on what is ‘good paperwork’, they are frequently far from experts in regard to documentation, and just repeat the old mantras.

I appreciate a patient refusing transport or being left at home as a decision of the paramedic involves a much higher level of risk, and therefore more stringent attention to detail in regard to paperwork, in particular to what information was given, capacity and consent. But what is the risk when a patient is transported and handed over to ED?

I am always surprised at the brevity of doctors letters, which frequently accompany a patient from home, or from a GP surgery, when an ambulance has been called to transport a patient to hospital. Frequently these letters take the form

“Dear Dr,

Joe Bloggs 24/06/40

Mr Bloggs has been unwell with worsening sob for the past 2 weeks. There is widespread crackles and wheeze, and I am concerned given his history of COPD and unresponsive to augmentin that he may need more intensive management in ED.

Hr 88, BP 150/80 Sp02 93% RR 16

Regards

Dr Smith”

In contrast, it would be quite common for a paramedic to arrive at this same patient and write a lengthy tale (in fear of the case ending up in coroners court) or perhaps even internal clinical audit.

It may look something like this:

“PC

Shortness of breath

HPC

78 year old male

Living independently in own home, retirement village with no home care arrangements

3/52 history of productive (grey green) cough, associated wheeze and shortness of breath.

Becomes very sob within 10m walk.

Difficulty managing at home, difficulty in performing basic self care tasks such as toileting and showering, due to SOBOE.

Previous icu admission for pneumonia

Loss of appetite over past week.

Day 3 of second course of augmentin without improvement

Seen by GP today at home, recommended attending ED via ambulance given history.

Denies chest pain on coughing.

No fevers, rigors

No urinary symptoms

No headache

No nausea

OE

Alert male, sitting upright in armchair during assessment GCS 15

Airway patent, verbalising, speaking in partial sentences

Breathing, rate 26, elevated. Deep and slightly laboured. Auscultation of chest revealed widespread wheeze. Sp02 on room air 93%. No cyanosis

Circulation, strong regular radial, rate 80. no pallor. No diaphoresis. Normotensive. ECG NSR.

Disability, perl GCS 15. BSL within normal limits.

Afebrile at 37.1.

Tx

Assist to stretcher

Monitor

IV access

Salbutamol neb x 2, good effect

Hospital

Handover to staff

Handover of GP letter, and one bag of patient belongings”

In fact, many Patient Care Record forms (electronic or paper based) already have drop down lists or check boxes for much of the information we write in the free text narrative section, there is always Airway, Breathing, Circulation, Disability sections, vital signs sections, GCS sections, pupil sections, temperature, Sp02 etc, yet we tend to repeat this information in the free text section, perhaps to give the impression we performed our assessment to a high standard, should we ‘end up in coroners court’.

I’m wondering if in reality, for a patient transported to hospital, we could generally be as brief as the GP letter above, considering the extremely low risk of anything ‘going wrong’ with this transport.

Please don’t think I’m trying to cut corners in regards to paperwork, it just seems that sometimes we are being overly thorough, in light of the doctors letter example above, and with the knowledge that the ED doctor will extract their own, much more thorough history than either the paramedics, or the GP.

I think this is relevant given the increasing pressures on paramedics to complete paperwork, clean and restock the ambulance in 20 minutes (15 minutes here in WA).

That’s a very thorough question, and the answer is probably ‘it depends on the case’ but we can work through some issues.

Business records

First, as has been noted before, a paramedics patient care record is a ‘business record’.  Business records are kept for the purpose of the business and are only of value if they record what actually happened.  Because business have an interest in ensuring their records are accurate courts can trust them.  What follows is that a business record can be tendered into evidence as proof that whatever is recorded on them is what actually happened (for further discussion see, for example:

The issue with business records, in the context of this question, is that they are expected to record what happened. That means if they don’t record what you might expect that is evidence that it did not happen.  In context you would expect a paramedic to note on the Patient Care Record form details of drugs administered.  If there are no details recorded that would be evidence that no drugs were administered. That is the basis for the teaching ‘if it’s not written down, it didn’t happen’.  That’s not an irrebuttable rule, the paramedic could give evidence that the drugs were administered and explain why it was not recorded, but the starting point is certainly if it’s not there, it did not happen.

Again keep in mind that what I’m talking about is matters that you would expect to be there.  If there is a ‘check box’ that’s not checked then whatever the box is recording did not happen.  But if we’re talking about something you don’t have a space for, eg the patient tells the paramedic something and it’s not recorded then the same rule won’t apply.  It is not usual for paramedics to write a verbatim transcript of the patient’s conversation so the fact that it is not recorded that the patient said something that is clinically irrelevant won’t prove the point.  Let me give an example:

Assume the patient asks ‘did you see my wife at home?’ and the paramedic replies ‘no, I didn’t, she wasn’t there’.  There is no apparent need to write that innocuous conversation down, but later the patient is charged with murder. The patient wants to call the paramedic to give evidence in order to argue that this conversation shows he did not know where his wife was and so therefore had not murdered her. Given that conversation is not something that you would expect to see recorded in the case sheet, the absence of the record does not prove the conversation did not happen.

So we can see the point we’re talking about clinically relevant material.  I will return to this point later.

What are good records?

The mantra from lawyers, particularly those in the health law field, is

 “good records, good defence; bad records, bad defence; no record, no defence”

But that begs the very question my correspondent has asked, namely what are ‘good records’.

As my correspondent notes it will depend on the case.  The record keeping is certainly an issue for risk management.  For the doctor (or paramedic) who thinks this is a very low risk transport there needs to be little more than the patient’s name and pick up and drop off address so the correct bill can be raised (see First aid patient records – who and what are they for? (January 31, 2015)).  For complex high intervention cases the records need to be more complete as they do need to show what interventions were done and why.

A difference between a doctor’s letter and a paramedic’s patient record

There is a difference between the doctor’s letter and the paramedic case record.  The doctor’s letter is the letter between one doctor and another.  The first doctor may have many other records regarding his or her treatment of the patient and there may also be other health provider records.  This letter then is for one purpose only.  The paramedic records are not only written to inform the receiving doctor of what was observed but forms the only record of the paramedic’s intervention in the patient’s life.

Should some issue become relevant (and you can’t know in advance what legal issues are going to arise in the future when someone may come back and ask if you noted something, or did something, or remember something) then it is the case that more complete records will always be better than less complete records.   Certainly, in the example given above if the patient dies, unexpectedly in the ED, and there are issues of why anyone did not notice they were in fact critically ill, the paramedic would want to be able to rely on their detailed notes.  The doctor too, would want to rely on more than the letter but he or she may have detailed records of their observations of the patient that help explain why they formed the view that they did.  In essence the paramedics record is likely to be their entire record, whereas the doctor’s letter is a summary of their entire engagement with the patient (however long that has been) but probably not their only record.

On a practical level, my suggestion would be that if “many Patient Care Record forms (electronic or paper based) already have drop down lists or check boxes for much of the information we write in the free text narrative section” then there is no need to write it in the free text section unless you are noting something unusual or the collection of signs and symptoms that cause you to form a diagnosis or treatment plan that may be outside the norm.  If all the observations are within normal range and can be noted using the drop down box/tick box etc there will be little value in ‘repeat[ing] this information in the free text section’.

The real question, as is so often the case in my response to paramedics, is ask what is clinically required in the patient’s best interest.  Take as given you should fill out the form your employer has given as the minimum, but if you are going to add more ask ‘is this required in the patient’s best interests’.  That is always a risk assessment, there is always a risk that that you will conclude ‘no’ and something goes astray and someone would benefit if you had asked or written more detail; but equally taking time and seeking and recording every minute detail ‘just in case’ is intrusive and does no-one any favours.

Conclusion

In conclusion my advice would be complete the patient record form designed by the service and if there is a box to check do what you need to do to be able to check the box, so if it asks for BP, take the patient’s BP.  But repeating it all particularly where everything is within normal bounds is probably unnecessary.