Hello hive mind.

So recently, and as a fairly newly appointed EMT FTO, one of the discussion points was made on areas that need massive improvement. Agency wide, of course, but I wanted to throw out a few points that are currently up for discussion after having watched 2 incredible Foamfrat videos pertaining to documentation and our inherent shortfalls. These two being Uncharted, and The Deposition

1) all times approximate. This, they noted is absolute suicide. Our task in the field is to be as precise as reasonable. Should a lawyer see this particular phrase in a narrative, it can literally spell demise to a clinician’s credibility. The question in turn becomes, “so if it is acceptable to roughly estimate your procedure times, is it also acceptable to roughly estimate your diagnostic values, including your blood pressures and pulses? And medication dosages estimated? Is it considered clinically acceptable to guess?” I felt this one hit very strongly as it was probably one phrase I remember seeing many times over the years.

2) No LOC. while not itself a detrimental observation, the concern becomes that the provider did not note from whom this information was collected. An instance where a patient is asked about a loss of consciousness that has a suspected head injury is themselves a much less reliable witness, due to the circumstances at hand. However, should a prover note an outside party, such as a family member, facility staff, or other healthcare provider that can attest from an outside perspective that no loss of consciousness took place, it becomes a much more concrete story. This can assist our personnel reduce themselves taking the brunt of the burden of proof from litigation, and call another provider from said healthcare institution into question.

3) contradictions and redundancies. They touched on this topic once during the Uncharted foam frat, and considering they discussed it again, leads me to suspect it’s a very strong talking point. Some providers are complacent in documenting drop downs where applicable, noting such minor discrepancies as not selecting a pedal pulse despite cms being a national standard for lower extremity injuries. This alone can call into question an employees credentials as a BLS skill that is so minor and overlooked being used by an opposed party to make a provider appear foolish. They note that there are certainly instances in where repeating something in a narrative is justified where they want to call clarification, or further stress how important a particular finding was. However, it was additionally stressed that the more one writes in a narrative, the more likelihood a contradiction can be made to a drop down or selectable menu choice, which was shown how easily and scrutinized the report and provider were when called to question.

Are there any other significant talking points that are addressable? I feel like these are good foundational tidbits for avoiding litigation, but I'm curious how the rest of the world has acted in regards to one of the most important aspects of our field. As well as so severely undertaught and a lack of importance stressed