While at EMS Today 2014 in Washington DC I had the fortunate opportunity to join host Scott Kier, EMS Blogfather Kelly Grayson, and the esteemed EMS Legal Practitioner Steve Wirth of Page, Wolfberg, & Wirth on a wonderful episode of The EMS Garage.
The topic on hand was about documentation. How we’re doint it, how we’re doing it wrong and what steps can we take in order to make it right? You can download the episode here or check out this video:
For those of you wondering, yes, this is the episode where it is revealed that EMTs and Paramedics do in fact diagnose.
Personally, I think there are a number of different take-aways from this discussion, other than the obvious gasoline can poured onto the “diagnosis or not diagnosis” firestorm. Here’s my quick list:
- There is often little evaluation or concern given to the writing skills of potential EMTs and Paramedics
- We don’t spend enough time during the foundation of EMS education on documentation
- There isn’t enough focus on documentation when onboarding and orientating new members at an Agency level
- We often ignore documentation best practices until it becomes a QA/QI issue which means its often too little and way too late
Interestingly, in a separate discussion with The EMS Siren, we talked about how we as EMS providers speak a multitude of “languages” to a variety of people. We need to be able to communicate to our patients on a level that they understand and are familiar with (Patientese), which is not the same level we have to be able to communicate with the nurses and doctors we will be handing them off to (Medical Terminolocus). Inbetween we also need to speak and deal with law enforcement (Five-Point-Ohish) and the fire service (Furnace). Our documentation often needs to be translated by medical billers (Reimbursementish) and stand up to the close scrutiny of lawyers (Legalese).
I’m a big proponent of a natural narrative for the conveyance of a patient’s acute condition and the events of the assignment because, regardless of what language you speak, everyone loves a story.
What are your thoughts on documentation? How are we doing? What are we doing wrong? How can we make it right? As always feel free to share your thoughts in the comments…