Legal Issues

what they say. If they have pain, be specific about the location of the pain and its quality. You should also describe the level of other symptoms, such as weakness or abnormal movements. You can use a pain scale to describe the patient’s pain.

There are just a few situations in which the patient will be unable to sign for consent to treatment and the Centers for Medicare and Medicaid documents. If the patient truly cannot sign their form, you should document why they could not sign the form and have an authorized family member sign for the patient. You should also document why the transport of the patient is medically necessary because the diagnosis alone may not be enough for insurance companies and Medicare to make a decision on that.

Be as specific as you can be about things like level of consciousness, pain level, vital signs, and physical findings. Be completely truthful about the visit as giving false information is a criminal offense. When giving treatments, note the treatment given and the time it is given. Be specific about what treatment was performed as well as the results of the treatment. This should be the case, even if you don’t see an effect of the treatment.

LEGAL ISSUES

While there are a few federal legal standards and laws governing EMS services, most laws regulating emergency services come from the different states. The most common thing an EMS provider would be some type of negligence, which is generally considered a mistake that is done without any ill intent. In order to prove negligence, the legal system will have to determine that there was some type of duty related to the patient— written, implied, or verbal. This involves some type of contract for care.

In order to prove negligence, the patient must show some type of duty to care existed and that this duty was breached or wasn’t done at all. Most commonly, the standard is what a reasonable provider of similar experience and education would have done under the same circumstances. This is what the standard of care is all about. A jury gets to decide what the standard of care should be and whether or not it was deviated from. Sometimes, the overseeing physician is brought into the lawsuit.