by Frank Myers
Originally published in MultiBriefs
Besides filling in "all the boxes," it is important to be as detailed as possible to provide a clear picture. The report or form needs to explain the necessary information clearly, in lieu of face-to-face communication for the next person down the line.
This is especially important when dealing with medical reporting. For instance, if the writer just writes "takes prescription medication" instead of writing the names and dosages for each medication — assuming that the transfer of care personnel are going to ask anyway — valuable time could be wasted in a life-threatening situation.
Also, even though it may or may not be relevant to what you need to render care, it clarifies the patient’s condition or past medical history for others — and enables care to be provided in a more expedited fashion with better results. This can also tie to recouping funds.
Many personnel at my former department would not put in zip codes, Social Security numbers and medical insurance info (phone number, policy numbers, etc.) because they did not want to do the paperwork! The USPS has a quick zip code search tool that can find the zip code by address. A few extra clicks is all it takes, but it saves time in the long run and helps the next person in line.
When we transported a patient, the report would eventually go to a collection agency to recoup our service fees for using our service.
Already having the policy numbers, patient IDs, group numbers, and Medicare and Medicaid numbers (if applicable) increased the chances of getting reimbursed for transport and treatment. This was somewhat important because we would get a percentage of all collections, monthly, in our paychecks, among all firefighters. The more we could do in the beginning increased the chances of collection, which at best was 50 percent.
Other reasons for filling in every field are to assure that "pencil whipping" or cut/copy/paste does not occur and to assure that "live info" is entered.
Many items can get overlooked — detrimental to the safety and care of individuals. Unfortunately, it becomes apparent when it is too late and accidents or injuries occur. Misinformation or missing information, such as detailing that an unconscious patient has allergies, can hamper care and healing. (Checking all boxes also applies to apparatus reports — e.g., bald tires overlooked on a vehicle inspection sheet can cause a vehicle to skid and get into an accident.)
Remember, if it was not documented, then for legal purposes it probably was not done!
I believe it is better to put "N/A" (not applicable) in a field than to leave it blank. It shows that you did not overlook anything, and that you are being thorough. The old expression of "crossing your T’s and dotting your I’s" goes a long way.
If you still fill out forms by hand, another useful tip is to make sure you write legibly. Some of us may need to practice a little more to assure clarity.
Another tip for filling out forms by hand, pen and paper is to use ink that does not bleed. Avoid "gel" type pens or others that can run in inclement weather. Use ballpoints and do your best to try to protect the paper from getting too wet.
A first glance at a report that has lots of information in it speaks volumes of the person that completed it. It makes apparent to the receiver that a thorough completed report has been done. It shows that the person, for the most part, takes pride and care in doing their job correctly.
Some people take the approach to be as "vague" as possible. That way if any legal ramifications were to occur, and testimony was required, a statement can be made to the effect "I don’t recollect."
The more details are given, the more prying that occurs from legal representatives. This does not bring positive creditability to you or your organization.
It is important to remember the details, not for your sake, but for the sake of others, especially when injury, pain, and suffering has occurred — resulting from unlawful acts by other individuals.
We always need to be detailed and thorough, especially when it comes to medical records, patient care, and inspecting vehicles or equipment needed for responses or important/necessary work-related operations. Lack of thoroughness can come back to bite you. It can appear that one is not taking their job seriously!