Simply put, incident reports are necessary in order to communicate information about an incident to those who were not there but need to know about the incident. In the case of EMS calls, reports are crucial for informing the next level of care about the patient's current condition and history, and to provide a record of the initial assessment and treatment. Other types of reports might provide valuable information for mitigating hazardous situations. For example, a fire report can prove invaluable to investigators in identifying a dangerous condition in a building.
But the most frequent reason for extensive report requirements is that they provide legal protection. We are repeatedly told, throughout both initial and recurrent training, that every report is potentially a legal record and that for legal purposes, "if it isn't written, then it didn't happen." While that saying is not absolutely true, it certainly is a premise that can minimize enormous future problems.
The legal power of an incident report was illustrated by a Florida medical malpractice case, Tallahassee Memorial Regional Medical Center vs. Meeks. That decision grew out of an incident in which two paramedics were called to the home of a 5-year-old child. They determined that no emergency medical care was needed, and neither transported nor consulted with a physician. Later that night, the child died of congestive heart failure. A jury awarded a $248,000 judgment against the paramedics and their hospital employer.
One of the paramedics testified at the trial that no one had informed her during the call that the child had a heart murmur. She also testified that she had made a misstatement on the run report when she wrote, "Doctor told them [the family] patient had 'heart murmur and heart beats too fast.' "
The plaintiff's attorney tried to discredit the paramedic's testimony by asking the paramedic whether she had written a follow-up report the following day, and made the same mistake again when she stated, "We asked her [the child's] mother if the doctor could have said that the patient had a heart murmur and she replied, 'Yes.' "
Even though this follow-up report was never introduced into evidence, it was used to impeach the paramedic's testimony. We don't know, of course, how much the jury relied upon the references to the written reports. But the verdict against the paramedics certainly implies that their testimony was not accepted.
This use of the report was initially upheld by the Florida Court of Appeals. Later, the Florida Supreme Court ruled that the incident report written the morning after the call was not admissible due to the particular language in the Florida statutes. However, the court also said, "But for this statutory privilege, it [the next morning's incident report] would have clearly been admissible." It was only because of a fine point of law that the paramedics were able to avoid having the words in their report used against them.
Lee Sachs is a Towson, MD, attorney who teaches seminars on a variety of legal topics for fire service organizations, including the Maryland Fire and Rescue Institute. He has a substantial knowledge of legal actions in which the adequacy of fire and EMS reports were at issue. Sachs offers this basic advice for all emergency responders:
- Do the job carefully.
- Document the call properly.
- Make sure you have insurance.
Sachs offers several specific tips on report writing that apply especially for EMS calls but are valuable for all types of responses. Be certain to record anything that is important for understanding the circumstances of the incident. In particular, complete a thorough patient assessment. He recommends using one of the common report outlines (e.g., SOAP) taught in EMT classes as a checklist. Distinguish in the report between the information provided by others (e.g., history or circumstances prior to arrival on the scene) and your own observations (e.g., conditions upon arrival on the scene). Record anything out of the ordinary, even in the case of refusals.
The Tallahassee case was a patient refusal. It well demonstrates the importance of accurately documenting an incident, even when no service is rendered. Although the judgment against the paramedics was ultimately overturned, the cost of litigation (in terms of time and stress, as well as money) no doubt was substantial.
We often think of proper reporting as being more important in EMS calls, both legally and operationally, than in fire or other property damage incidents. But there certainly are negligence cases involving fire operations. The principles of effective reporting are the same - only the subject detail is different. It is important on fire calls to report anything out of the ordinary, and to document the actions that are taken. For example, Sachs cites the problems that inevitably follow a rekindle. In such cases, it helps immensely if the fire report documents that the original fire was extinguished and that the structure was properly checked by the appropriate official.
Incident reports do not have to be massive documents but they must record all that is important or unusual. We should write quality reports for both their legal and operational benefits.
Steve Blackistone will moderate a panel of attorneys focusing on fire service issues at Firehouse Emergency Services Expo '98 in Baltimore July 16-19.
Steve Blackistone, a Firehouse® contributing editor, is an attorney and a member of the Bethesda-Chevy Chase Rescue Squad in Montgomery County, MD.
