Exposing Patients: Reluctance to Document

Jun 12, 2009
Star Of Life Law
EMS Documentation, Pt. Assessment, Trauma

I cross posted my original post over at Paramedicine 101. In the comments there, a commenter listed as WTF stated:

What ridiculousness. Treat your patient with the respect and dignity they deserve, end of story. This business about exhaustive documentation of “the exposure” as if it were an incident is asking for trouble. I have never, ever ever seen a patient’s chart document an exposure like you suggest it should be here.

“I first uncovered her left breast to check for deformities or discoloration, found none, and then immediately covered that breast with a towel that I had readily available. The examination spanned a period of approximately 10 seconds, and I averted my eyes in such a manner so that I never fully appreciated the entire breast in one clear image, but rather in aggregate parts. I then proceeded to examine the right breast…..”

Seriously?

I think WTF pushes the point into the absurd. If you re-read my suggestions on documentation, I feel they are reasonable and do not advocate the absurdity expressed by WTF.

Exposure is part of the trauma primary survey. Documenting your exposure of the patient should fall in line with documenting the other parts of your assessment within the trauma primary survey. You do document the other parts of your primary survey, right?

If your patient arrives in the ED sans clothes, and you didn’t find them that way, then exposure was an intervention that you performed in the medical assessment and treatment of that patient. In my opinion it should be documented.

Keep in mind that your documentation may be used for purposes other than review by the ED physician and your agency’s QI/QC committee. Your documentation may need to be used to educate 12 jurors why you needed to do what you did, and more importantly, what you actually did on the call.

If it is not documented, it didn’t happen. Should you try and later argue you did something, but didn’t document that you did it (for whatever reason), your entire PCR is then thrown into question.

I don’t understand the reluctance to fully document what we do in the field.

Update: Want some insight as to how documentation comes into play during a malpractice/negligence action, or how in a deposition the plaintiff’s attorney will pour over your documentation word by word? Read this ongoing series about White Coat’s trial.

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7 Comments

7 Responses

  1. Adam Thompson, EMT-P
    June 12, 2009 at 7:31 pm

    I think you are correct. I have noticed that documentation thoroughness usually reflects the possibility of the call to come up again; whether for QI or a legal matter. What I mean by that is that if you know that you have a high likelihood of having to give deposition in the future, you are more likely to document more details. I think this may be how what you are advocating may be used. On the average call, uncovering a geriatric, I might just write “patient exposed for assessment”. If it is a 16 y/o female I might write something like “the patient’s clothing was removed to inspect for further injury. After no injury was found the patient was promptly covered with a sheet”. I would make sure the caregivers present were documented as well. This is a great topic for discussion. Thanks for your input and expertise.

  2. WTF
    June 15, 2009 at 2:46 am

    (Same commenter here as the other website)

    Perhaps I took it a step farther than what you intended, but the message remains. We shouldn’t have to be so afraid of litigation that we are forced to justify every single mundane decision in our paperwork.

    When I take someone down the stairs on the stair chair I don’t document “Patient extricated from residence on stair chair in order to reduce cardiac workload, O2 demand, and any potential ischemia/infact that may result from physical exertion.” No. I simply write “patient extricated on stair chair.”

    When I decide to take the back roads instead of the highway on the way to the hospital due to a traffic jam, I don’t need to actually write out my reasoning. I simply write “patient transported to hospital.”

    As prehospital providers we are constantly making decisions. When to treat, how to treat, where to treat, how to move the patient, what to do with the gear, what to tell family members, who to bring along, who to call, what to say, and what to do. Who is to say that any of these decisions requires documented justification more than others? Why is exposing a patient for a physical exam an “intervention,” and the route you navigated to the hospital not? Don’t they both have potential to effect the outcome of our patient? Why should one be documented exhaustively, and the other not?

    I would advise that prehospital providers treat every single patient with respect and compassion. I think open communication between provider and patient (when possible) is absolutely essential, and documentation of the RELEVANT assessment and treatment be completed in a clear and concise manner. Trying to cover yourself for every possible legal contingency is no way to provide medical care, and frankly, is an impossible goal anyways.

  3. Star of Life Law
    June 15, 2009 at 5:20 pm

    WTF:

    I have read you latest comment numerous times in an attempt to get to the point of your contention with my post. Rather than reply, point by point to your post, I prefer to reply merely to what I perceive to be your main point of contention.

    From your comments, it appears that you feel I advocated over-documenting the exposure of a patient, and that somehow (yet unexplained) this is harmful or bad.

    Over-documentation is an oxymoron.

    Exposing a patient is relevant and does need some level of documentation. You have to choose what is level of documentation you feel is right for you.

    I sincerely hope when you next expose a patient that as you write your PCR, you pause and think critically as to how you document it. It may be simple. It may be elaborate. Regardless, if you simply think about it then this post was successful.

  4. WTF
    June 24, 2009 at 11:33 am

    OK, how about this:

    Overdocumentation of mundane tasks (such as the preparatory process for a physical exam, or the route the ambulance drove to the hospital) lengthens the prehospital care report to a point where the important information – that information necessary to ensure the continuity of medical care – becomes obscured. Doctors and nurses are busy people, and if they can’t read a PCR and get the relevant info (*patient had chest pain, it started while walking, feels like his last MI, 12 lead info, I gave nitro with relief*), then that is an obstruction to that patient’s medical care. The level of documentation you suggest, I believe, puts an emphasis on the least important things to the detriment of those that are the most important (CYA over medicine).

    I also take issue with the logic your suggestion is based upon. I asked the question, if this level of documentation is suggested for an “exposure” because it is an “intervention,” then why shouldn’t we exhaustively document other events that could also be called “interventions,” by the same standard? The route the ambulance drove to the hospital, justification of my IV catheter size and placement, number and location of seatbelts applied to the patient, etc etc etc. If this is your standard for an “intervention which must be documented,” do you also suggest that these other things should be documented in detail as well? Where does it end?

  5. Joseph Schmoe
    July 28, 2009 at 12:10 am

    While both sides present valid arguments, WTF’s last question sums it up for me. Where does it end?

    BTW, I’m 2-0 in litigation, so my documentation appears to be adequate.

  6. Star of Life Law
    July 30, 2009 at 11:19 am

    Joseph and WTF,

    I appreciate both of your comments and see what you are pointing towards. My answer at this time is that it ends where you are comfortable with it ending.

    Additionally, I feel that while exposure as an intervention is similar to “IV catheter size and placement” and WTF mentions, exposure is also different in one very big way that IV size and placement isn’t.

    Exposure has a higher potential for being the starting point for a complaint or lawsuit than does IV size or placement, or any other of the examples mentioned.

    My post was meant to raise awareness of this increased potential and offer guidance on ways to limit or reduce that potential. I wanted people to think critically about exposing patients, and to ask themselves what type of actions or documentation would they want to have in their PCR should a complaint arise.

    If you have found a way that works for you, that you are comfortable with, then stick with it.

    I appreciate both of your comments on this topic and hope that you will continue to read the blog and offer your insight and experience.

  7. Headaydom
    November 25, 2009 at 5:18 pm

    Thank you looking for details. It helped me in my responsibility

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