Documentation: The Finishing Touches

In the past several issues of this journal we have reviewed elements of the SOAP format for documentation. It is my belief that SOAP is a very simple and thorough documentation tool, and is effective when the EMTs have asked for the subjective information they need, searched for the objective information they need, and determined a plan of care according to the subjective and objective information they have obtained. As I have stated before, there is a reciprocal relationship between assessment and documentation: good documentation depends on good assessment, and knowing how to do good documentation helps a person do a better assessment.

Today’s article will conclude this series by looking at a few tips for fine-tuning our run sheets. What we want is documentation that reflects exactly what the patient looked like before we began to treat him, reflects exactly what we did to treat him, and reflects how he responded to the treatment we provided. A run sheet that shows those three things completely is going to be adequate for all of the purposes for which our documentation is used, including continuation of care, legal defense, quality assurance, billing, and education.

Subjective: everything that the EMT is told, and wouldn't know otherwise. The EMT must ask the right questions to get the information he needs; he must not rely on the patient to just volunteer it.

Objective: everything that the EMT discovers by examining the patient and his surroundings. The EMT must determine what needs to be assessed, and assess it. He must not rely on the patient to just point out what needs to be examined.

Assessment: what the EMT thinks is wrong, based on the subjective and objective findings.

Plan: everything the EMT has done in caring for the patient, written in the order it was done, with times and other details indicated when appropriate. Must include an evaluation of the patient's response to the treatments, and any changes in the plan made based on that response.

Watch your language!

No, we don’t need to be English majors to write good run sheets, but we do have to have a good grasp of basic grammar skills. Consider the following situation: the run sheets says, “Patient’s personal physician called and advises transport.” Does that mean the doctor called the patient and told him to go to the hospital? Or does that mean the patient’s doctor was called, perhaps by the patient, perhaps by the EMT, and when called, the doctor told the caller that the patient is to be transported? Sometimes, in an effort to be as brief as possible we leave out words that give meaning to a sentence. How about “patient advised he has high blood pressure.” Again, does this mean you were checking his blood pressure, noticed that it was high, and advised him of this fact? Or perhaps that you were checking his blood pressure and he said to you, “oh, by the way, I have high blood pressure.” If an EMT writes “IV x 2,” does that mean she has started two IV lines, or that she has started a single IV but it has taken her two attempts? We must pay attention not only to the words we put in, but the words we choose to leave out, because one missing word can change the entire meaning of a sentence.

Spelling is important, too, much to the dismay of many practicing EMTs. An EMT who writes that a patient had a “sinkable episode” might have done a commendable assessment and provided excellent care, but his credibility might be doubted simply on the basis of his not knowing how to spell the medical expression “syncopal episode.”

LOLINAD-FDGB and other acronyms

We all know it’s much easier and takes less space and time to write common acronyms and abbreviations rather than spell out the words they represent. Everyone knows ABC’s is airway, breathing, and circulation, and IV is intravenous. But is LOC loss of consciousness or level of consciousness? Is OD an overdose, or referring to the right eye? Is BS referring to breath sounds or bowel sounds? LS lung sounds or lumbar spine? Is Fem female or femoral? Is a history of an “Inf R arm” an infusion in the right arm or an infection of the right arm? (And speaking of which, did you know that the “arm” is technically the upper arm, just as the “leg” refers only to the thigh? Remember that distinction the next time you describe a patient with pain in his “leg” — do you really mean his pain is only in his thigh, or do you mean from hip to foot, in which case it would more accurately be called “lower extremity pain,” not “leg pain.”) And last, there are those who would ask if WNL really means “within normal limits,” or “we never looked.”

We have seen “NKM” in many run sheets in the medications box — writers making this abbreviation up obviously figure that, if NKA means no known allergies, then NKM must mean no known medications, right? But it makes no sense — how often does a patient not know if he’s taking any medications? In a situation in which the patient is unconscious and the EMT does not know if the patient takes medications, then writing “unknown” in the box makes sense. But mostly when we see “NKM” it’s used to mean “none,” i.e. that the patient takes no medications. It would be so much clearer, and only add one extra letter, to write out the word “none.”

And while we’re on the subject of abbreviations, we must be careful to use them correctly. I can’t count the number of times I have seen written on a run sheet, or been given in a radio report, that the patient has been exposed to “C-O-2.” Well, of course the patient has been exposed to CO₂ — people around him are always exhaling! Obviously, what the EMT means is that the patient was exposed to carbon monoxide, CO, not carbon dioxide, CO₂.

Another thing I see often is arrows, and I am often left wondering what exactly the writer intended. If there is an up-arrow preceding the words “spine pain,” does that mean that the patient’s upper spine is painful, or that there has been an increase in the pain in her spine? If there is an up-arrow preceding the abbreviation “BP” in the phrase “pt. states BP,” does that mean that the patient’s blood pressure today is elevated above his normal, or that the patient has hypertension as a medical condition?

There are lists of acronyms and abbreviations in almost all textbooks, as well as in many pocket references and handbooks. Unfortunately, many times even those don’t always agree. Even if a service has adopted a standard set of terms for documentation on its run sheets, an EMT may work for two or three services, and not be able to keep track of where it’s okay to use which expression. If we have any doubt at all as to whether an abbreviation or acronym is a standard term and will be understood by anybody at any time and in any field of medicine, we should write the word out entirely instead of abbreviate it.

By the way, are you wondering what the acronym in the subtitle of this section means? Little Old Lady in No Apparent Distress, Fell Down Go Boom. While it may serve a purpose in giving us a chuckle, acronyms such as these have no place in our professional documentation.

We don’t “Rule Out.”

Many EMTs of all levels write as their “Patient’s Suspected Problem” “R/O” and then what they think is wrong. R/O cardiac. R/O fracture. R/O appendicitis. As much as we’d like to think we can rule these things out, we cannot. We don’t have the capability of ruling out. We simply “suspect.” Sometimes, as when we see bone ends sticking out, or ST elevations in three contiguous leads on the cardiogram, we can even be more certain than just suspicious, but in even those cases, we are not “ruling out.” Write your suspected problem without preceding it with “R/O.”

Didn’t you already say that?

Filling the entire narrative section with words is a good thing, right? It brings to mind high school and college writing assignments, where the teacher would ask for a four-page paper and some people would turn in 20 or 25 pages, thinking if four is good, more is better. Just because there are a lot of words in the narrative doesn’t mean it’s good; it just means there are a lot of words in the narrative. The mistake many people make is repeating in the narrative box information they’ve written elsewhere, just to fill the narrative up. But if, for example, they’ve already written the vital signs, allergies, and medications in their appropriate places elsewhere on the form, they don’t need to repeat them in the narrative.

Details, details, details…

One thing people who don’t like SOAP say is that it doesn’t provide defensible details, times, sizes, etc. And I say, why shouldn’t it? The Plan doesn’t need to be “here’s what I’m going to do,” but rather, “here’s what I’ve done.” That means it can (and should, for that matter) list what was done, in chronological order, with as much detail as necessary to describe completely everything that was done. A lawyer looking to prove that you provided substandard care might suggest that the cervical collar you applied to your spine-injured patient was the incorrect size. Can you look at your run sheet and find where you indicated what size you used? One looking to prove that, had you provided oxygen to your patient earlier, she wouldn’t have ultimately suffered brain damage, would be hindered in that effort by finding that you indicated in your documentation that immediately during the initial assessment you had provided high flow oxygen by BVM with an OPA in place, then placed an [x] size ET tube at [time], visualized the tube going through the cords, observed equal chest expansion, heard good bilateral lung sounds and no gurgling over the stomach, confirmed placement with an ETCO₂ device, immediately placed a cervical collar, continued documenting breath sounds and chest rise at the appropriate times throughout transport, and so on. The lawyer might still try to discredit your activities, but the more details you provide, the less likely you will have to try to rely on your memory to prove that you did something right.

What’s the plan, Stan?

It’s not enough simply to say in your Plan that you’re going to do frequent vital signs, or that you’re going to observe for mental status changes, or utilize the Maine Spinal Assessment Plan. You need to document what the vital signs were, that there were (or were no) mental status changes, what the findings of the spinal assessment were, etc.

Who’s the patient, anyway?

Another example of the “more words is better” philosophy is the run sheet that is full of examples of how the EMT treated himself. “I was called to the scene of...,” “I applied PPE...” The run sheet is about the patient, not about the responder.

In another instance of “who’s the patient?,” sometimes we’re called to a scene with a number of patients from the same incident. In those situations it’s important to remember that each run sheet is specific to one patient. Keeping that in mind, we have to avoid the tendency to say, “three patients in vehicle, all patients deny injury” on each of those patients’ sheets. This run sheet is only about this patient. While the fact that another victim in the same vehicle has been killed might be significant, it is generally not pertinent to write about the conditions of other patients on one patient’s record.

Deja vu all over again

We all transport “frequent fliers,” and of course, they are always the ones with a medical history as long as our arm. While it’s tempting to shorten our documentation by referring to previous calls for this patient, “See run sheet number 123456 for previous medical history,” or even, “patient states feeling same as/better than/worse than before,” without defining what “before” felt like, it shouldn’t be done. Unfortunately, neither the receiving staff nor other responders to this patient’s home have access to previous documentation to know what the referred-to previous record showed. Every record must be able to stand alone, no matter how many times we have been to that patient’s home, and no matter how many times we have to repeat that long history.

UFOs

Extra pieces of patient information, medication lists, discharge instructions, electrocardiograms, monitor strips, photographs, all should be labeled with, at a minimum, the date, patient’s name, date of birth, and state run sheet number. Without these identifiers, a medical record that is dropped and comes apart, or one that is tossed at the hospital into a bin with records from other patients, can easily fly away and later be mis-filed or discarded.

Hieroglyphics

Illegibility. Nobody who is physically capable of performing EMS skills is physically incapable of writing legibly. People simply choose not to take the time or make the effort to write legibly. And there is no excuse for it. If a person is continually being asked by others what this or that word is, that person needs to slow down and write better. Perhaps switch from cursive to printing. But to simply say as an immutable fact, “I have lousy handwriting” is as lame as saying “I never learned how to use the equipment in my ambulance.” If you don’t know how to use the equipment, find somebody to teach you. If you don’t know how to write legibly, take the time now to learn! A neatly-written run sheet invites reading. A sloppy one gets ignored. A sloppy run sheet also implies sloppy care.

I remember when I was an EMT student being told by a more seasoned EMS provider that, whenever he wasn’t sure about something, he just scribbled it so nobody would be able to tell what he had written. I don’t think I even need to address the absurdity of that.

Nobody ever reads these things, anyway!

The reality is that the majority of our run sheets will not be read by the staff at the facility to which we have brought our patient. The staff will be relying both on our verbal report and on their own assessment findings. What that means, though, is that when somebody does read our report, it’s because he or she is looking for a particular piece of information, possibly long after the call is over. Our report needs to be thorough enough that he or she can find that information. So, who might be looking? Maybe it’s the person who does billing for the service, looking for documented evidence of medical necessity for that transport. Or possibly it’s an attorney, who is going to be examining your record with a fine-toothed comb because the patient did not have a good outcome. So while the majority of our records may not ever be under scrutiny, it’s the one that is that must be complete, and since we don’t know which one it will be, all of our records must be complete.

I know I said it, but that’s not what I meant.

The objective findings of a paramedic’s run sheet indicate that a patient has a bleeding laceration along the hairline. The plan includes IV, monitor, transport, and re-evaluation. The re-evaluation findings are, “Head wound continued to bleed.” I would like to think that the paramedic did something other than simply notice the bleeding, and then the continuation of the bleeding, but I wouldn’t be able to prove it based on what was written.

If you’re going to have to make an excuse, do something different.

We’re taught that if we stray from our protocols, we need to document the rationale. But that doesn’t mean whatever rationale we come up with is acceptable. If what we are going to write as our rationale is weak, maybe we’re better off re-thinking the decision to stray from protocol or standard practice. If we’re going to have to write that we were “unable to measure pulse rate because child was wiggling,” and later find ourselves having to defend that decision, what can we say? Sure, we’ll be explaining why we had trouble, but we still won’t explain why we didn’t figure out how to get a pulse measurement anyway. Or if we’re going to write that we’re “unable to get finger stick blood sugar because not enough blood,” we’ll be creating a suspicion of a patient in a much more life-threatening condition than perhaps we had intended. Anytime we’re going stray from the standard of care, we need not only to write down why, but we need to evaluate whether the “why” is defensible, either to the staff in the emergency department, to our QA officer, or to judge and jury should the patient sue a couple of years later. If the “why” is not going to be defensible after the call, we need to choose a different course of action during the call.

10-55 is not a chief complaint!

Remember, the chief complaint is supposed to be a description of what the patient tells you is wrong. If the patient at a 10-55 tells you nothing is wrong, then his chief complaint would be, “no complaint,” or “denies complaint.” The fact that he was in a MVC is the setting, part of the history, but not the chief complaint. You wouldn’t think of writing “bedroom” as the chief complaint of a person found in her bedroom complaining of chest pain!

Over the past several months we have examined the anatomy (the component parts) and the physiology (how they all work together) of our run sheets. It is my hope that these articles have helped you look at your documentation with an eye toward constantly striving to make it better. No run sheet will ever be perfect, but every run sheet is a new beginning, an opportunity to work on improvement.