ABSTRACT: The best protection from liability is good patient care. The best protection in a malpractice proceeding, however, is good documentation. ("If it wasn't written, it wasn't done.") Improving documentation skills requires personal effort and practice, practice, practice. However, Charly Miller's exciting presentation style helps providers discover enjoyment in charting, inspiring them to gain self esteem by excelling at something previously-considered tedious or mundane.

A one-hour, didactic only, presentation discusses universal documentation rules (water-proof, ball-point, black ink pen pressed firmly, and writing or printing clearly, etc.); documentation methods for vital signs, times, and events; S.O.A.P.- vs. STORY- form patient documentation; and differences in charting medical vs. trauma emergencies. A two-hour workshop combines all the didactic information with student exercises in documentation.

Conference coordinators may want to consider Charly's
"Talk the Talk And Walk the Walk" Workshop
- combining "Write It Right" with "It's All Greek To Me" (a medical terminology presentation).

LEARNING OBJECTIVES:
After attending the "Write It Right" presentation, participants will

1. understand that good documentation provides the best protection in a malpractice proceeding.
2. recognize that documentation skills development is a personal responsibility requiring study and frequent practice.
3. understand universal documentation requirements.
4. understand the importance of correct documentation of vital signs, times, and events.
5. recognize the difference between S.O.A.P.- and. STORY- form patient documentation, and differences in charting medical vs. trauma emergencies.
6. (in workshop situations) demonstrate the ability to document patient contacts, using medical terminology, abbreviations, and symbols.

1. INTRODUCTION: "The best protection from liability is good prehospital care." And, "The best protection in a malpractice proceeding is good documentation."

2. "Drudgery" vs. "Exciting Personal Challenge": Yes! Improving documentation and charting skills requires personal effort, study, and practice. However, documentation and charting skills can also be viewed as something to Take PRIDE In! Discovering the enjoyment of excelling at documentation and charting results in an increased amount of Self Esteem, yielding great personal satisfaction, a sense of accomplishment, and earns the provider an increased enjoyment of Professional Respect.

3. Various "trip sheet" / "run report" form examples are reviewed, including discussion of the newly-developed portable charting computers ("palm-pads").

4. Universal Basics for "old-time" forms are addressed: Ball-Point pen, black (or blue) water-proof ink. Press Firmly. Write or print clearly. Fill in all boxes or spaces.

5. Event Record Information is discussed: crew identification, trip number, date, time, location, mode of response, assisting agencies, pt. statistics and billing information.

6. Recording Event / Activity Times are discussed: actual time of occurrence vs.
   use of activity-notations as "time" notations.

7. Vital Signs Record Requirements: 2 Sets Minimum; "serial" VS; Palpated vs. auscultated B/P VS: palpated B/P documentation; respiratory rates (and techniques for correctly counting them).

8. Documentation or Orthostatic VS changes: using stick figures to
   indicate patient's position during VS measurement.

9. Body of Document Contents: Description of event, complaints, MOI; Exam Findings; Assessment Conclusions; Tx Rendered; Response to Tx.

10. Importance of a Standard Pattern of Report, both Verbal & Written!: Discussion of development of personal patterns that serve to
    • remind provider of things to observe for.
    • assist provider to report completely and consistently.

11. "S.O.A.P." charting format.
    • S = "SUBJECTIVE" Observations & Information: Pt./Witness "Story" & "Scene information"
    • O = "OBJECTIVE" Observations from Physical Exam (PE).
    • A = "ASSESSMENT (Dx).
    • P = "PLAN" = Treatment rendered (Tx)

12. EKG STRIP documentation: Importance of a STANDARD PATTERN
    for verbal AND written EKG reports.

13. SOAP patterns for documentation of TRAUMA EMERGENCIES
    (motorvehicular accidents, penetrating trauma, blunt trauma, and falls).

14. "STORY-LINE" documentation styles for CARDIAC ARRESTS
    (and other long or evolving types of calls).

15. Crime Scene Documentation:
    • Pt. MEDICAL report = ONLY information germane to Pt's medical situation.
    • Criminal observations belong on a POLICE REPORT - NOT a medical report.
    • Preoccupation with "Kojak" report (reporting criminal evidence) results in neglect of documenting the clinically significant PT medical information.

16. BASIC "RULE" OF DOCUMENTATION:
    "IF YOU DIDN'T WRITE IT, IT DIDN'T GET DONE!"

17. PRACTICE SCENARIOS for PRACTICE CHARTING (both medical and trauma scenarios).

18. SUMMARY

Email Charly at: c-d-miller@neb.rr.com
Those are hyphens/dashes between the "c" and "d" and "miller"