Death by Documentation

Many of the legal failures found in departments related to discipline, employee terminations, EMS response and documentation or other departmental events is due to the failure to document those events carefully with consideration that you may be challenged in those personnel decisions, in the provision of medical care or on a fire response.

It seems like a no brainer that on EMS or Fire events, there are templates provided by the EMS authority, your department, your State ((Medical Incident Report Form (MIRF)) or the Feds (NFIRS) that takes the effort out of documenting the response, yet we continually fail to use all of those resources contained in those resources to adequately document the event and if the event takes a turn for the worse and your department is sued, you will depend on that documentation, good or bad to defend your actions. Aside from the two areas mentioned above, the area that fire departments are constantly challenged are personnel issues and this is the area we do a terrible job in documentation.

Let’s look at two high hazard areas that create problems for fire department that providing adequate documentation may make a difference in litigation.

Emergency Medical Services – Documentation of the EMS event preserves real time information related to the care provided by the Firefighter/EMT or Paramedic. On the Medical Incident Report Form (MIRF) either in a paper or electronic form, it is imperative that ALL of the boxes are completed with accurate information and there is a well written narrative describing the patient care provided. This medical narrative should describe the treatment provided and some pertinent negatives of treatment not provided and the reasons for that decision. In a legal challenge to your patient care (usually the patient has died) the narrative will be used by the plaintiffs’ attorney alleging faulty medical care and your attorney in the defense of your actions. A well written narrative can be used to refresh your memory of the event in a deposition and at the time of trial which may occur three years or more after the event.

Personnel Actions to include Terminations – one of the most difficult actions a Fire Officer takes is the discipline of a firefighter. Discipline generally results from a firefighter’s failure to adhere to established Policy or Operational Guideline and is designed to improve the behavior and conduct of the firefighter. Departments must have a well-designed progressive discipline process that takes the firefighter through a series of verbal warning (one time) up to termination. Many departments will give the firefighter a verbal warning without documentation for the first violation of Policy unless the violation requires more severe action. In a progressive discipline process for repeated violations of Policy, the process involves: verbal with written documentation, discipline with suspension, demotion or termination depending on your department Policy. During every step of this progressive discipline you must provide adequate documentation of the events and the outcome of the process. Terminations are the most difficult, as the department must adhere to a strict time schedule (due to a labor agreement or prevailing State law) including the right to representation and a series of hearings to allow the firefighter to defend their actions. Detailed documentation must occur at each step of this process based on the challenges that will be forthcoming after you terminate your firefighter.

There is nothing worse for a department to have to reinstate a frequent violator of your policy due to an insufficient discipline process and a failure to adequately document the entire process.

When documenting any event occurring in your department, you must incorporate the following concepts:

• Is your documentation complete? Read and reread your documentation, make sure you check your spelling and punctuation before filing.
• Does your documentation show compliance with Department Policy, Procedures and department protocol?
• Does your documentation follow the Labor Agreement, State or Federal Law?
• Did you utilize terms describing the event with a correct meaning?
• Did you document the important issues?
• Did you write something to hurt yourself or your department such as your opinion or hearsay?
• Did you write enough to avoid reliance on memory?
• Did your file the document(s) in the employee’s personnel file or some other secure place within the organization?

Excellent writing is an art form and as leaders, we need to do more to train our firefighters and fire officers on how to correctly document potentially damaging events in the department and how to adequately place the facts of the issue on a document.