Medical Documentation: Understanding Legal Responsibilities with Case Examples Essay

Submitted By FireLaw
Words: 4285
Pages: 18

Understanding your responsibilities in accurate documentation ◦ Medically and Legally

Vehicle Accidents
◦ Criminal and Civil Issues
Getting Lost
◦ Bad Dispatch Information
◦ Crew unfamiliarity with service area Abandonment
Dropping Patients
Dead Equipment Problems
◦ “Dead Defibrillators”
◦ Empty Oxygen Tanks
◦ Inoperable EMS Equipment

Patient Care Issues
◦ Airway Management
◦ Improper Extrication
◦ Spinal Immobilization
◦ Wrong Medications
 Dosage Problems
 Overmedication
 Out dated medication
Over 80% of EMS litigation is not directly related to patient care.

Personnel Issues
False Certifications or Credentialing
Sexual Assault
Unauthorized Disclosure
 Facebook

Surprise developments in the Ryan Widmer murder retrial were "devastating for the prosecution,". ◦ Revelations that two versions of the same medic-run report exist, unbeknownst to two prosecution witnesses who testified Friday.
◦ Paramedic supervisor and chief investigator for the Warren County coroner, testified they were unaware of the second version of the document until 21 months after Sarah Widmer, 24, drowned in her
Hamilton Township bathtub.

Each of those points is “just another rock on the mounting rock pile of reasonable doubt,” State
Prosecutor Allen said.

The defense for Widmer uncovered a mysterious second EMS run report.
◦ Ems Left one at the hospital and created another after they were made aware of the homicide investigation

Paramedic testified that four attempts were made to put a tube down Sarah's throat.
◦ Widmer's defense attorney, asked, "So if I am doing the math right we had two attempts in the bedroom by Mr.
Stevens. Two attempts by Mr. Rose so that would be four?
◦ Then in an effort to discredit emergency workers,
Widmer's attorneys pulled out the two EMS medical records that show inconsistencies. One record shows one attempt. Another record shows five.

1st Medic Unit – 5AM
◦ Child in Respiratory Distress
◦ PM Advised to place child in shower
◦ No documentation
2nd Medical Response – 1:45 PM (same day)
◦ Child remains in distress
◦ Child transported to hospital by 2nd PM unit and later died
Sources indicate:
◦ Paramedic did not fill out any paperwork on the medical call including signature from child’s parents refusing transport to the hospital.

Required by law:
WAC 246-976-330 Ambulance and aid services - Record requirements: 

Agency name
EMS personnel on the incident
Date and time of medical emergency
Time of onset of symptoms
Patient vital signs including serial vital signs where applicable
Patient assessment findings
Procedures and therapies provided by
EMS personnel
Any changes in patient condition while in the care of the EMS personnel
Mechanism of injury or type of illness

Required by Department Protocol
◦ Protocol 900.01.08
◦ All EMS patient care report shall comply with Washington
Administrative Code (WAC), and Snohomish County
Guidelines, Protocols,
Procedures, and Directives
(SOG 900.01.02).

Wright v. City of Los Angeles 219 Cal. App. 3d
318 (1990) – Duty to Act
◦ EMS finding a patient lying on the ground had a duty to perform an examination sufficient to determine if the patient has an illness or injury
◦ The failure to perform this examination could result in death or serious injury and is negligent
 Wright died at the scene a very short time later from
Sickle Cell Crisis.
 The paramedic was found liable and the plaintiffs were awarded millions.

Zepeda v. City of Los Angeles 223 Cal. App. 3d
232 (1990)
◦ There is no duty of care to a victim until EMS undertakes examination and treatment
◦ Once EMS begins examination and treatment, a duty of reasonable care is owed.
 Shooting, scene unsecure, paramedics waited for the police, Zepeda died.
 Court stated - No “special duty” to provide aid. They received the call, responded quickly, and were prepared to manage the call so long as the scene