(4 min read) Emergency Medical Service (EMS) documentation continues to be one of the most vexing challenges for EMS practitioners and agency leaders alike. Good documentation is essential to reducing legal risk, ensuring proper and accurate reimbursement, collecting valid data, and maintaining agency compliance. Poor documentation can raise risks in all these areas for EMS agencies.

Educating EMS professionals across the U.S. on documentation principles is something we (PWW attorneys) spend a ton of our time doing. Whether through the Certified Ambulance Documentation Specialist (CADS) course that we developed for NAAC (the National Academy of Ambulance Compliance), or through our custom, in-house agency workshops, teaching sound EMS documentation skills is the single busiest part of our law practice. I recently presented on this subject at the 2021 ZOLL Summit Series ePCR & Fire Event, and the legal case studies are compelling enough to share here.

Appropriate Care, Negligent Documentation

Our presentation of legal case studies in which documentation issues were central to court cases is one aspect of documentation training that is particularly effective for training EMS providers.  

In the case of DeTarquino v. Jersey City EMS, an Advanced Life Support (ALS) crew transported a patient who had been injured during an assault to a local community hospital, where they were discharged after evaluation. The patient later experienced a grand mal seizure and, after EMS was called again, was this time transported to a trauma center. The patient subsequently went into a coma and died of an intracranial bleed.

The patient’s family brought suit, alleging that during the course of treatment and transport by the first EMS crew, the patient had vomited, but the crew had negligently failed to document that fact on their PCR. The lawsuit alleged that this documentation oversight was critical, because documenting the fact that a head-injured patient had vomited could be a sign of a potentially serious head injury, and had it been documented, the initial hospital would not have discharged the patient. The Court of Appeals agreed, finding that allegations of negligence specific to EMS documentation can be stated separate and apart from allegations regarding negligent patient care. As a result, the court ruled that the qualified immunity for acts of negligent care do not protect EMS caregivers when it is alleged that their documentation was negligent.

In short, this case cautions us that there is a separate and distinct standard of care for EMS documentation, and that your documentation can be negligent even when your patient care is not.

Explanation of Risks of Refusal of Care

In another illuminating case, Browning vs. West Calcasieu Cameron Hospital, a court invalidated a signed patient refusal of care form because the crew had not taken the time to explain to the patient the risks of refusing care. In that case, a woman had refused care, despite showing signs that could have indicated a potential myocardial infarction (MI). The crew minimized the patient’s symptoms, saying that she was probably “minding the heat,” and obtained a signature on their refusal form. Since the court found that the crew failed to apprise the patient of the risks of refusal, however, the release of liability language on the refusal form did not protect the EMS providers.

This case strongly demonstrates that the legal protection in a refusal of care situation comes not from the patient’s signature on a refusal form; the true protection comes from explaining the risks of refusal and the benefits of treatment/transport to a patient who needs it, and then thoroughly documenting the discussion that took place and the risks that were disclosed, as well as the patient’s decision to accept those risks.

Documentation Deficiencies and Deviation from Clinical Protocols 

In yet another case, Henslee vs. Provena Hospitals, the court found that numerous documentation deficiencies — including a crew’s omission of failed intubation attempts — constituted evidence of deviation from their clinical protocols, which rose to the level of gross negligence. This case tells us that sparse or poor documentation — including notable deficiencies of issues that should be addressed in a PCR (like all treatments and interventions provided or attempted, even if unsuccessful) can deprive EMS providers of the defense of qualified immunity and directly lead to liability.

Quality Documentation Protects EMS Providers and Agencies From Liability

These are just a few of the many court cases where the quality of EMS documentation (or the lack thereof) became a central issue giving rise to liability on the part of EMS practitioners and EMS agencies. Remembering these important lessons and applying them in your daily documentation practices can make the difference if your agency’s care is ever called into question in a court of law.

Read More on how Proper Documentation Protects EMS Agencies From Liability:

EMS Compliance Lessons from a $10M Medicare Ambulance Fraud Scheme

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