Covering Your ASSets for Court || EMS Documentation

Most EMS providers have heard CYA or “cover your ASSets” 🍑 in reference to report writing at some point in school or on the job. 

What does this really mean? 

The emphasis on thorough documentation has become progressively more paramount in the last decade and for good reason. It is no secret there is a growing trend of lawsuits in various healthcare fields, including emergency medical services. This may be due to increased awareness, media coverage, higher expectations from the public or regulatory bodies or just an overall more litigious environment. One of the best ways to protect yourself is through thorough and honest documentation. If you have not ever personally been put in a situation where documentation protected you from disciplinary action at work, termination, licensure revocation or even jail time, PCRs and narratives may only seem like a nuisance. 

Although at times they are inconvenient, they are so very necessary. 

Examples: 

You (EMS provider) bring in a patient complaining of a headache and reports experiencing a fall hours prior. After performing your assessment, you grow increasingly concerned that the patient may have a brain bleed 🧠 or TBI. You report this to the RN or doctor. They do not seem worried or rushed. You, again, explain your concerns and the signs & symptoms that have you wanting to take this patient straight to CT yourself. They inform you that they will take the patient back for a CT scan and you leave the hospital relieved. The hospital staff does not get a CT scan and gives the patient medications for a migraine upon discharge. The patient returns home and dies in her sleep from a brain bleed due to her fall. The family sues the hospital for negligence. You were protected, however, because you documented the presentation, your concerns and what was relayed to the hospital staff. 👩‍💻

You (EMS provider) pick up a patient involved in a MVC. The patient ran their truck off the road, hit a tree and smells strongly of alcohol. You attempt to gauge if the patient is alert and oriented of person, place, time and event. He cannot answer any of your questions and appears injured. He is treated, transported to the hospital and later arrested. You now learn of a lawsuit against you and your crew. The patient is claiming he was kidnapped and forced against his will to the hospital. You were protected, however, because you recorded his mental status and injuries. In fact, you also obtained the witness signature (law enforcement) that was present when your assessment was conducted. ✍🏻

Although these are fictional stories (with a sprinkle of real life events), instances like this happen ALL THE TIME! 

I had an FTO once tell me that if I didn’t document it, it didn’t happen. Wise words.

You have to protect yourself, your crew and your patients (going to address how patients are protected through documentation in another post)! 

You seriously never know when you will receive the subpoena that will change your whole life….and if you will even remember the minute details of the call without reading the narrative.

Is it report-writing monotonous? Yes. 

Boring? At times.

Could it change the trajectory of your future? ABSOLUTELY! ⚡️ 

Protect yourself and document, document, document! 📝

If feel comfortable, please share an example of when documentation saved your 🍑!