EMS Documentation

I hope everyone enjoyed their Fourth of July celebrations, which includes still having all fingers attached, and a break from the Medical Director Message. This month we are talking about the not-sexy or exciting but very important documentation. Remember, anyone assessed, injured, ill, or has a significant mechanism to presume injury is a patient, including the “simple” calls of lift assists. Every one of these patients needs a set of vitals. The term VITALS are aptly named as they are “absolutely necessary and important.” A complete set of vitals include:

• BP (systolic and diastolic)​

• Pulse

• Respiration rate

• SpO2

• Pain (when appropriate)​

When your patient’s vitals are abnormal, they must be repeated and monitored closely for changes. Vitals shall also be completed before and after treatments and prior to any transfer of care. Anytime vitals are unable to be obtained, you need to document the situation that precludes you from obtaining a complete set of values. Anytime a procedure or assessment is incomplete, you must document the deviation from the protocol. Documentation of deviation helps the reader of the patient care report understand the circumstances of the care, while helping protect you from litigation and QA messages from your medical director.

One part of the documentation I forgot to include in this month’s presentation is words and phrases to avoid in your reports. Those who are fans of the hit TV show M*A*S*H may also know the show Dragnet. One of the catchphrases from the series was “just the facts, ma’am”, and that is the goal of any medical documentation. Most importantly, you want to:

• record and report vitals

• how the patient was found when you first arrived

• what injuries you observed

• how the patient was acting

These pieces of information are important to describe the situation. You should describe wounds as you observe them, but not use words like ENTRY, EXIT, or SELF-INFLICTED. You can describe a burn, puncture, or missile wound but refrain from the phrases GUNSHOT WOUND, KNIFE WOUND, CIGARETTE BURN, and CIGAR BURN. 

The last item I want to discuss is the use of the proper names for days of the week and months in your documentation. When trying to convey the passage of time, you should document “3 days ago” and not write “Friday.” I use this example as this message will come out on a Monday, so Friday should be 3 days prior. By using the proper name, you place the burden on the reader to understand the temporal relationship of the information you are providing. If “Friday” is in the report, then the reader has to look to see what day of the week the report took place and figure out how many days “Friday” is from the day of the report. This same idea holds true for using the proper name of months. To make things easier, and when referencing prior events, use relative terms like “2 days ago” and “6 weeks ago.”

John B. Hill, MD

Emergency Medicine Physician

UH Portage EMS Medical Director

UH Portage ED Trauma Liaison

July 17, 2023 - Emancipation

Emancipation

I have received many questions this month about the emancipation of minors, so this week we will dive into some of the specifics. The information that follows comes directly from the Ohio Bar Association article from 2020.

A minor is someone who is under 18 years old and is supported by a parent/guardian who is responsible for his or her actions. A minor does not have the rights or responsibilities of an adult. For example, a minor cannot vote, serve on a jury, get credit in their name, or enter a legal contract. Someone who turns 18 and is enrolled full-time in high school is no longer a minor and has the same legal rights and responsibilities as an adult, but the parent/guardian is still legally obligated to support the minor until graduation.

“Emancipated” is defined as being freed from parental control, care, and custody. Generally, a child is emancipated after reaching 18 or upon graduation from high school if the child is already 18. Ohio law generally refers to “emancipation” and “age of majority” when referencing child support obligations of parents. A parent must support a child until the child reaches 18, or beyond age 18 if the child continuously attends a high school on a full-time basis, they are mentally or physically disabled and incapable of self-supporting, or if parents agree to support beyond age 18 in a separation agreement or decree. Until a court decides a minor is emancipated, the parent/guardian must support a minor and are held responsible for the minor’s actions.

Ohio law says that the child support obligation may end earlier than age 18 if the child marries, enlists in the military, is deported, or if they are emancipated by a court. The court determines emancipation on a case-by-case basis and must be satisfied if the minor can financially support him or herself and take on adult responsibilities. Emancipation cannot be accomplished by an act of the child alone, and Ohio law does not allow for such a request. Emancipation generally arises in the context of child support cases.

While getting married typically constitutes emancipation and ends parents/guardian responsibilities, becoming pregnant and having a child does not. When a minor has a child but is not married, the minor’s parents/guardian continue to be responsible for the minor and is still legally obligated to support the minor. This same structure then applies to the new parents being legally obligated to support the new baby. This can create a situation where a minor is the responsible party for an infant but cannot make decisions for themselves.

John B. Hill, MD

Emergency Medicine Physician

UH Portage EMS Medical Director

UH Portage ED Trauma Liaison

July 24, 2023 - Consent to Treat Minors

Ohio law considers people 18 years of age or older to be capable of giving valid, legally enforceable consent to receive medical treatment. Generally, people under the age of 18 (minors) must have the consent of a parent or guardian before receiving medical care. However, there are several exceptions to this general rule, such as emancipated minors (which we covered last week), statutory exceptions, mature minors, and absences of the parent/guardian. We will also discuss who the custodial parent is when dealing with children of divorced parents.

The law spells out certain situations in which a minor can give consent for medical treatment; these are called “statutory exceptions.” In these situations, the patient must still have decision-making capacity.

A minor may consent: 

• to an examination for the purpose of gathering physical evidence of an alleged sexual offense such as rape (ORC 2907.29)

• for the diagnosis or treatment, by a licensed physician, of any venereal disease/STD/STI (ORC 3709.241)

• for the diagnosis or treatment, by a licensed physician, of any condition reasonably believed to be caused by drug abuse, beer, or intoxicating liquor (ORC 3719.012)

• to be given an HIV test for the diagnosis of AIDS or an AIDS-related condition (ORC 3701.242)

• to donate blood to a nonprofit voluntary program if at least 17 years old (ORC 2108.31)

• to receive mental health treatment, if at least 14 years old, for a limited number of sessions or outpatient services, except for the use of medication (ORC 5122.04)

• to receive an abortion if the minor has applied to the local juvenile court and the court finds “good cause” to bypass parental notification (ORC 2919.121)

• Healthcare providers generally must provide emergency medical treatment to preserve life and prevent serious impairment to the health of any individual, including a minor. (ORC 2317.54)

Healthcare providers generally must provide emergency medical treatment to preserve life and to prevent serious impairment to the health of any individual, including a minor. If the health care provider cannot reach the parents/guardians within the time available to preserve the child’s life or prevent serious impairment, the emergency takes precedence over the requirement to obtain consent. If the situation is not life-threatening, and the child does not fit one of the exceptions listed above, the health care provider cannot legally treat the child until a parent/guardian has given consent. Most EMS interactions with minor patients fall into the emergency medical treatment category.

Ohio has adopted but is not codified into law, a “mature minor” rule which allows a minor to consent. A mature minor is over age 15, can demonstrate to a health care provider that he or she has enough maturity and understanding to make medical care and treatment decisions without parental/guardian consent. On a case-by-case basis, the health care provider uses the same criteria that would be used to determine if an adult has the capacity to make medical decisions. If the minor is found to have the capacity to consent, the health care provider must give the minor the same informed consent an adult would receive. The protocol does not recognize the mature minor and strictly adheres to the age of 18 for consent purposes. If you believe the mature minor rule will be used as the basis for consent to treat a patient, a call to online medical control would be advised.  

If a parent/guardian is going to be away, they can give permission, in writing, to another adult (such as a friend or relative) to authorize a child’s medical treatment in their absence. 

Which parent can give consent to treat can be a little confusing, so we will look at all the situations. If the parents are not divorced, then either of the child’s parents may give consent. If they are separated but not yet divorced, then either parent may provide consent. If the parents are divorced, but both parents have legal custody (shared parenting), then either parent can sign. If the parents are divorced, and one parent has legal custody or is the child’s custodial or residential parent, then that parent should give consent. However, if a delay in medical care would be dangerous for the child and all reasonable attempts to reach the custodial or residential parent have failed, then the non-custodial parent can give consent.

John B. Hill, MD

Emergency Medicine Physician

UH Portage EMS Medical Director

UH Portage ED Trauma Liaison

July 31, 2023 - Calling the Coroner

The crime scene guideline in the protocol shall be used when law enforcement personnel advise EMS that they have responded to a crime scene, or EMS determines that a crime scene may exist. The purpose is to ensure the protection of the patient’s welfare as well as to ensure the ability to conduct an effective and thorough investigation of the crime.

If you find yourself on a known or suspected crime scene:

• Make sure you and your partners are safe

• Summon Law Enforcement if not already present

• Lead EMS provider may request entry of safe area to determine viability of patient

• Stay in visual contact with your partner and Law Enforcement

• Summon additional resources to the patient side only as necessary

• Minimize scene disturbances

• Enter and exit on same path

• Do not go anywhere else on the scene except as necessary for patient care

• Always wear gloves

• Avoid pools of blood

• Minimize personnel to only those required for patient care

• Do not cut through knife / bullet holes in clothing

• Do not go through patient’s effects

If a patient is believed to be viable, follow appropriate treatment protocol for situation. The patient should be removed from the crime scene as soon as possible and transported to an appropriate facility. If your patient is handcuffed, a law enforcement officer with a key must travel with EMS and the patient in the back of the ambulance. Law enforcement cannot follow behind the ambulance because EMS personnel have no way to remove the handcuffs if necessary, for example to obtain IV access or extricate the patient if the ambulance was involved in an MVC (Motor Vehicle Collision). If any relevant information is learned, make sure to relay any information discovered to law enforcement as soon as possible.

If a patient is believed to be Dead on Arrival (DOA), one provider shall approach and attach cardiac monitor to confirm death. After apnea, pulselessness, and asystole are confirmed, contact medical control for time of death, document the physician who pronounced the patient, and do not move the body. The coroner’s office should then be notified of the death.

Ohio Revise Code 313.12 states the coroner’s office shall be immediately notified “when any person dies as a result of criminal or other violent means, by casualty, by suicide, or in any suspicious or unusual manner, when any person, including a child under two years of age, dies suddenly when in apparent good health, or when any person with a developmental disability dies regardless of the circumstances.” When calling the coroner’s office simply state, “I wish to report a death” and be ready to report the following information:

• Demographic data concerning the deceased, such as: name, age, sex, race, and marital status

• Time of accident or onset of cause of death (date/time)

• Location of body

• Time of death (hour of day and date)

• Name of physician pronouncing

• Next of kin, address, telephone

• Place, mode, and manner of injury

• Place of death

• Name of person reporting, date, and time

• Pertinent information, circumstances surrounding the death including weapons, guns, rope, duct tape found near and around the body.

John B. Hill, MD

Emergency Medicine Physician

UH Portage EMS Medical Director

UH Portage ED Trauma Liaison