Sloppy Moe’s and Slick Mic’s PCR Writing Styles....(revised!)

            A Patient Care Report (PCR) is a record produced by the Emergency Medical Technicians immediately after an ambulance call has occurred. Sometimes, the accuracy within a patient care report mirrors how appropriately the patient was treated. A PCR can reflect upon the caregiver in a positive or a negative manner. Consider the writing styles of two fictitious medical professionals who earn their living
as Emergency Medical Technicians (EMTs). From the perspectives of PCR reviewers, their co-workers and dubious trial lawyers, Sloppy Moe and Slick Mic each appear to have a unique style of PCR writing. Despite being proficient EMTs, their different styles of writing have earned well-deserved criticisms and complements.

Sloppy Moe, although having potentially astonishing technical attributes, has a tendency to take shortcuts when writing a PCR. When producing a PCR, Sloppy Moe has an inclination to want to simply say, “The patient lived; the end.” Sadly, a complete picture of what signs and symptoms the patient presented, or what treatment they received, is not always included in the documentation. Ironically, Sloppy Moe is a brilliant writer who earns fair revenue creating written masterpieces relating to his private life. When developing insightful documentaries portraying interesting facets of his worldly adventures, he invests great attention to the inclusion of details. However, Sloppy Moe does not always feel so inclined to include this level of detail in the writing of his PCR. Possibly, the brevity is from fatigue created secondary to other pursuits, or perhaps, it is owing to the nature of chronically performing the exhausting routine involved in writing a PCR. Either way, even when the report warrants more information, Sloppy Moe often succumbs to a ‘short, sweet, and to the point’ chronicle.

 Sloppy Moe’s personal interests frequently take priority over fully completing a PCR. He often rushes writing a report in order to get back to the station so he can get more sleep or visit with friends. He, more often than not, prematurely generates a report so he can then ‘graze towards a feed trough’ for his next meal. Moreover, he commonly shortens his data entry with the intention of soon leaving, thereby avoiding potentially being in the proximity of the next call. These are just a few of numerous reasons his reports sometimes lack details. Sloppy Moe meets minimum requirements in his PCR documentation, but often some particulars of the incident or care are not included.

Take, for example, the simple case of an intravenous therapy blunder. The case involved a dehydrated patient who had not received any intravenous (IV) therapy. Intravenous therapy is the standard care given to dehydrated patients. The IV fluids help to re-hydrate the patient. Just prior to Sloppy Moe’s participation in the call, someone else had failed to re-stock the ambulance with IV fluids. Since he had just come in to work, and had no opportunity to inspect his ambulance, he was not responsible for the lack of supplies. He was, however, responsible for his failure to document the circumstances that led to not providing the standard of care. It appeared to the PCR reviewer Sloppy Moe had been neglectful in his care, and therefore, would be liable for malpractice. Fortunately, Sloppy Moe convinced the reviewer to seek evidence that substantiated his defense. That is just a simple example of how critical it is to document.

 There is a saying in medicine: “If it wasn’t documented, it wasn’t done.”  There could just as well be another one: “Just because it was done, doesn’t mean it needs to be documented.” The ‘eyes of the beholder’ occasionally belong to readers who believe creative documentation is unnecessary. Slick Mic is an author of such creations.

Slick Mic, another skilled and competent Emergency Medical Technician, has a tendency to record excessively when writing a PCR. He goes beyond meeting the minimum requirements for writing a PCR. Slick Mic creates a narrative that not only memorializes the patient to the extreme, but one that also sometimes includes extraneous information. Slick Mic, to the best of his ability, attempts to construct a tool for recounting beyond all essential details. Slick Mic knows his document is more permanent than his memory; therefore, he includes more-than-enough details to refresh his memory. He believes, should his document ever become evidence in a court case, it is more apt to be in a very distant future.

 For instance, Slick Mic once received a summons to testify in a murder trial two years after someone else had written the patient care report. Because the report lacked vital bits of information, their PCR was useless in prompting his memory. The PCR could have enabled Slick Mic to describe the scenario better to the court and could have helped to validate the patient’s treatment. Slick Mic has also avoided direct involvement in another trial after a lawyer read his patient care report. Due to the inclusion of significant details, which invalidated his client’s claim, the lawyer dismissed the case, and declined to pursue the issue further.

To the untrained eye, a PCR may simply appear to be a legal document created in a medical format. To a lawyer, who has a background as a physician, a review of that same record may reveal omissions of care, or a lack of appropriate assessments and interventions.  Other reviewers may also ‘read between the lines’ in search of (and discover) a treasure of buried information. Such findings, when disclosed through quality control efforts and measures, ultimately tend to lead to improvements in patient care. But, when found in court, these treasures may pave the way to proving a case of negligence, and thus, lead to a costly lawsuit.

 Fortunately, for patients, his co-workers and employers, Sloppy Moe will continue to have his incomplete reports scrutinized by a multitude of critics. Unfortunately, not all readers of Slick Mic’s creations have learned to appreciate the completeness of his reports either. Nevertheless, it is undisputed, that although Slick Mic is meticulous and occasionally over-documents, and although Sloppy Moe often under-documents, their patient care is mostly prudent and very much appreciated. The defining difference between their writing styles is, to Slick Mic, the PCR is more than just a mere medical-legal document that must contain the minimum amount of information. It is a chance to create a precise, detailed testimonial that reflects positively upon the caregivers and memorializes all of the patient care involved in the incident. To him, writing the patient care report is an opportunity of a lifetime; it is a memorable manifestation of how well the patient was cared for.