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Charting: Two Schools Of Thought


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#1 TheMarsh60

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Posted 14 August 2011 - 06:37 PM

Hi everyone.

My company, a RW, seems to be split in two regarding proper charting methods. One the one hand you have those who are in favor of the chart-by-exception method. That is, put in the information that is necessary, don't repeat yourself; a just-the-facts-ma'am approach.

The other school of thought is to put as much information as possible into the chart. Double-documentation is less of a concern in favor of painting as clear a picture as possible.

The justifications I've heard are the following.

The by-exception folks state that, should they be deposed, they would prefer to have only the facts as stated in the chart on which to go by. The thought being here that there is less noose with which to hang yourself, so to speak. A favorite quote by one of our RNs on the stand is, "I can only comment as to what's on the chart."

The lots of information folks state that, in the event of a deposition, it is best to put as much information as possible in order to be able to remember the call and be able to add your commentary as the provider on scene.

I've been in EMS ten years now, and have yet to see a PCR/Charting course taught by someone with a legal background. I'd venture that this is a cause why we have such divergent opinions (not just in my current place of employment)on how to chart.

I'd like to know your opinions on this. Which style you prefer, and why?

Thanks for the time, everyone.

Brian
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#2 Jwade

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Posted 14 August 2011 - 08:45 PM

Hi everyone.

My company, a RW, seems to be split in two regarding proper charting methods. One the one hand you have those who are in favor of the chart-by-exception method. That is, put in the information that is necessary, don't repeat yourself; a just-the-facts-ma'am approach.

The other school of thought is to put as much information as possible into the chart. Double-documentation is less of a concern in favor of painting as clear a picture as possible.

The justifications I've heard are the following.

The by-exception folks state that, should they be deposed, they would prefer to have only the facts as stated in the chart on which to go by. The thought being here that there is less noose with which to hang yourself, so to speak. A favorite quote by one of our RNs on the stand is, "I can only comment as to what's on the chart."

The lots of information folks state that, in the event of a deposition, it is best to put as much information as possible in order to be able to remember the call and be able to add your commentary as the provider on scene.

I've been in EMS ten years now, and have yet to see a PCR/Charting course taught by someone with a legal background. I'd venture that this is a cause why we have such divergent opinions (not just in my current place of employment)on how to chart.

I'd like to know your opinions on this. Which style you prefer, and why?

Thanks for the time, everyone.

Brian


Brian,

Excellent questions....

My first thought is WOW....It scares me to think that the RN to which you refer to has been deposed so often that he or she has been able to come up with a " Favorite Quote"

My other thoughts take me back to grad school and a couple of semesters of business / healthcare / criminal law. Of all the case law we researched and studied ad nauseum, indicated, of those healthcare practitioners successfully found guilty, IMO it was because of a SEVERE LACK of detailed documentation. Im sure a few people will disagree as you mentioned above, however, after reading so much actual case law, I subscribe to the " If it was not charted, it was not done" methodology. If you have nothing to hide, you should not have a problem charting facts, yes, some attorney's can try to use those against you, but, really, any second year law student would be able to counter the argument easily.

Here is a " favorite quote" from my criminal law professor......

If you can't argue the facts, argue the law
If you can't argue the law, argue the facts....

Pretty much the crux of the legal system today.

Respectfully,
JW
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John Wade MBA, CCEMT-P, FP-C, RN

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#3 pureadrenalin

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Posted 14 August 2011 - 11:41 PM

I chart as much as possible. I tend to write so much that some of my narratives arent' read in full as the QA people don't worry about what isn't in my reports. Our med director loves how much I write. I've seen where I work be as simple as

C/C, how PT found, one, maybe two sets of V/S, interventions, and "transported to ED"

Nothing else. Now that is scary. It would read something to the effect of...

"88y/o female, c/c of chest pain. PT found seated in chair. V/S assessed. PT had IV started, PT moved to ambulance, PT on cardiac monitor, 12 lead transmitted, 324mg of Aspirin given, 2x nitro given, PT transported."




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#4 TheMarsh60

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Posted 15 August 2011 - 02:00 AM

JW, great response, and thank you.

Pureadrenaline, I think I might not have been clear as to what I meant. That is some scary/lazy charting you cited. However I'm talking about a line that's probably a little more blurred in reality. The opinions at odds here come from experienced care providers, the charting from which isn't a blatant example of poor documentation. This is more a difference in style.

Let me give an example so we're on the same page.

There are certain common sense things we all hope our colleagues remember to chart, however some things come under dispute.

There are details like, 'Pt secured in aircraft without complication,' and, 'pt tolerates assent to altitude / tolerates descent without difficulty' that many find superfluous to place in a chart on the grounds that doing so sets a bad precedent. In other words you can't realistically document every single second of pt. care, so reporting significant events and changes in the pt status only is the way to go.

Others state that such details show you are constantly assessing the patient and paying attention as appropriate. Some will put "No change in pt status" every five minutes in their narrative or timed notes just to show this, while others will have only three or four timed notes for an entire call.

Hope this clarifies some of what I was talking about.

Cheers all.
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#5 MSDeltaFlt

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Posted 15 August 2011 - 02:47 AM

I never chart wondering whether or not it will go to court. I chart as much as I can. If I get deposed, then I get deposed. If I don't, then I don't. I've got way to much on my mind regarding charting than to worry about the frivolous chance of getting subpoenaed.

Take care of your patient and prove you took care of your patient.
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Mike Hester, RRT/NRP/FP-C
Courage is resistance to fear, mastery of fear - not absence of fear -- Mark Twain

#6 BackcountryMedic

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Posted 15 August 2011 - 02:20 PM

I never chart wondering whether or not it will go to court. I chart as much as I can. If I get deposed, then I get deposed. If I don't, then I don't. I've got way to much on my mind regarding charting than to worry about the frivolous chance of getting subpoenaed.

Take care of your patient and prove you took care of your patient.


Amen.

I'm in the chart a lot group. "chart by exception" is like WNL to me (we never looked).
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#7 pureadrenalin

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Posted 15 August 2011 - 07:00 PM

Ahhh...yep...looks like I missed the boat. Lol.

It does clarify. And in the terms you speak of..yes..i chart similarly to that. Every time I get a new set of vitals, comes a full reassessment of interventions and patients status, and if there are changes, I note them. If not, I make a simple note to the effect of..

"With vitals at XX:XX hrs, all interventions rechecked, patient reassessed for changes, none found, interventions fully intact and working as expected, IV patent and running etc"


I think anything less than that shows laziness, or that once your patient was stabilized you just hung out for the rest of the transport.
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#8 chris

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Posted 16 August 2011 - 01:32 AM

Ahhh...yep...looks like I missed the boat. Lol.

It does clarify. And in the terms you speak of..yes..i chart similarly to that. Every time I get a new set of vitals, comes a full reassessment of interventions and patients status, and if there are changes, I note them. If not, I make a simple note to the effect of..

"With vitals at XX:XX hrs, all interventions rechecked, patient reassessed for changes, none found, interventions fully intact and working as expected, IV patent and running etc"


I think anything less than that shows laziness, or that once your patient was stabilized you just hung out for the rest of the transport.


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#9 chris

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Posted 16 August 2011 - 01:35 AM

I have been deposed. If you did not write it, you did not do it. Make sure you chart everything you did and if it is a decision that could go either way, make sure that you chart why you did what you did. Good patient care and safety first. Very first thing she told me when I asked about how to chart and mistakes people make.
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#10 Mike Mims

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Posted 16 August 2011 - 04:07 AM

Hi everyone.

My company, a RW, seems to be split in two regarding proper charting methods. One the one hand you have those who are in favor of the chart-by-exception method. That is, put in the information that is necessary, don't repeat yourself; a just-the-facts-ma'am approach.

The other school of thought is to put as much information as possible into the chart. Double-documentation is less of a concern in favor of painting as clear a picture as possible.

The justifications I've heard are the following.

The by-exception folks state that, should they be deposed, they would prefer to have only the facts as stated in the chart on which to go by. The thought being here that there is less noose with which to hang yourself, so to speak. A favorite quote by one of our RNs on the stand is, "I can only comment as to what's on the chart."

The lots of information folks state that, in the event of a deposition, it is best to put as much information as possible in order to be able to remember the call and be able to add your commentary as the provider on scene.

I've been in EMS ten years now, and have yet to see a PCR/Charting course taught by someone with a legal background. I'd venture that this is a cause why we have such divergent opinions (not just in my current place of employment)on how to chart.

I'd like to know your opinions on this. Which style you prefer, and why?

Thanks for the time, everyone.

Brian

The reason you don't have members from the legal community involved with the aspects of charting is because regardless of what you write/type it will be scrutinized, questioned and analysed by "expert-witness'" to cast doubt.

Yes you can stick with the cliche' "If you did not write it, it did not happen" but, it's what's important that needs to be documented. There's no way you can or do document everything that you and/or your partner did or performed.

This is where knowing your job is priceless, e.g.; your protocols, policies and procedures they are there to protect you.

I can guarantee you that if you deviate from you protocol(s), you are on your own. Plus you're not the only one that will be sued; The Program/Company, Training Personnel/Department, Management and Co-workers all will be included.
It'll make it real easy to prove some negligence if the paper-trail determines that the documentation was there and provided, that you KNEW what to do or NOT to do. So, the next time you pencil-whip something or someone does it for you, remember there maybe unavoidable life changing consequences..........
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Mike Mims

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#11 TheMarsh60

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Posted 17 August 2011 - 02:28 AM

Wow, great response from everyone. It's appreciated.

Mike, not sure I've ever pencil-whipped something, and hope I never get in the habit. But I'll say thanks for the warning, and the informative response.
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#12 Mike Mims

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Posted 17 August 2011 - 12:54 PM

Wow, great response from everyone. It's appreciated.

Mike, not sure I've ever pencil-whipped something, and hope I never get in the habit. But I'll say thanks for the warning, and the informative response.


It wasn't directed towards you personally, just people in general.



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Mike Mims

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#13 old school

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Posted 18 August 2011 - 12:05 AM

Yes you can stick with the cliche' "If you did not write it, it did not happen" but, it's what's important that needs to be documented. There's no way you can or do document everything that you and/or your partner did or performed.


.....and Mike hits the nail square on the head!

The whole point of charting is to document what you found, what you did, and how the patient responded. That's it. Those things are critical and leaving them out can get you in a lot of trouble.

However, it doesn't generally take much writing to do that. Ever read a ICU doc's progress note, or a surgeon's operative note? They document less about a 2 hour surgery than many paramedics do about routine, 20 minute transports.

Sometimes, clearly documenting what happened takes some space. But usually it doesn't, and using paragraph after paragraph to try to "paint a picture" and list impertinent details is unnecessary and may contribute to making things harder for you if you are ever deposed.

"Documentation by exception" is an accepted charting strategy because it is time effective and legally sound. It's leaving out important things that gets you in trouble, not leaving out minor details that have no impact on the patient's outcome.
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