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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.