If the administration of a patient being put through the medical industry can be seen as a kind of athletic relay race, then a patient report form is the service provider’s baton that they have to hand over. With any mistakes or messing around in handing over the patient report form, all of the other administrators of the patient’s medical affairs, as well as the patient’s treatment, are disrupted.
Patient report forms are actually legal documents, that provide a record of your assessment and treatment for other medical professionals who may treat the patient after you. If that record is incomplete or inaccurate, somebody may provide additional patient treatment that is harmful to the patient’s health. If you get sued, patient report forms are a record of the patient treatment you gave, and a solid defence in court. If you state a fact in court that is not on the patient report form, it can be rejected as a defence.
For the sake of easy interpretation by those after you, your patient report forms need to be neatly and legibly filled in. Preferably get a colleague to assist you if in any doubt – you might understand your ‘hieroglyphics’, but that doesn’t mean everybody else does. Avoid using shorthand and/or symbols instead of proper words and terms. For example, do not write ‘#’ for fracture, but rather the full description of the fracture, such as ‘fractured left humerus’. Also, do not use acronyms – such as STI for ‘soft tissue injury’, to further prevent misunderstandings.
Remember that a mechanism of injury is not a diagnosis. For example, ‘blunt trauma to the left forearm’ is not a diagnosis, but actually the source of the injury. The injury should be specified, such as for example, ‘contusion of the forearm’, ‘laceration of the forearm’, or ‘abrasion of the forearm’. Noting the injuries as ‘multiple abrasions/lacerations to whole body’ is also not a suitable diagnosis. The specific area and type of injury must be individually noted. For example: ‘Laceration right hand’, ‘laceration right forearm’, ‘laceration right shoulder’, ‘abrasions to right cheek’, and ‘bruises to right side of ribs’.
Your patient report form and the notation it contains will be assessed by every medical aid scheme before the claim is paid. Ensure that your patient report forms are completely and properly filled in. If your patient report is either incompletely, or improperly filled in, there is a good chance that the claim will be rejected and the patient report form will need to be corrected and resubmitted. This back and forth process can dramatically slow down the cash flow of any ambulance operation and can be detrimental to the long term growth and sustainability of that operation. It is critical that all staff members within the ambulance operation are aware of the importance of correctly completing patient report forms.
Honesty and conciseness in the notation of a patient report form are extremely important. Do not over-state or under-state injuries, and do not note any fictitious injuries. If you support an ambulance service in committing fraud by falsifying any injuries or medical conditions, you may be held equally liable with them for that fraud. It is equally important not to falsify vital signs or to assume that vital signs provided by a medical facility or fellow practitioner are still valid. Total transparency is not only legally safer for you but also the ethical approach.
It is your responsibility as a practitioner to take accurate vital signs on a regular basis. You should be assessing the following vital signs as a bare minimum, even for patients who do not show any signs of poor health: Pulse (for rate, rhythm, and strength), respirations (for rate, rhythm, strength), blood pressure, level of consciousness, hemo glucose level, pupil reactions, and lung sounds. This way you and your colleagues will not be caught by any nasty surprises.
In summary, it may seem like you’re saving time out in the field by taking shortcuts in filling out the patient report form. But you’re not. As they say, sometimes ‘slow is smooth, and smooth is fast’. The amount of trouble you can cause for the patient through incorrect treatment, for yourself through legal claims, and for your ambulance service through injury to reputation and hampering their cash flow, is enormous. It’s time to perfect your patient report forms, and show that you are a truly professional and caring medic.