What is the name of the document in which the EMT should document all patient findings and treatment?

Introduction

Many situations that first responders may find themselves in are also potential crime scenes. Police understand the priority of providing emergency medical care. The goals of emergency medical services (EMS) and police may diverge at any time while these professionals are at the scene of a crime. Differences arise due to potentially conflicting responsibilities, and both services take actions that they in good faith believe are most important and of greatest priority at the time. With a proper understanding of these differences, patients may be properly and quickly cared for while maintaining the integrity of forensic evidence to the greatest extent possible. It is important to understand the responsibilities of EMS personnel and law enforcement when they respond to the scene of a crime. When arriving on the scene of a serious crime, law enforcement is focused on numerous tasks that must begin immediately. Their first responsibility is to ensure that any threats or risks of harm are mitigated. Preventing additional injuries or loss of life to the public, police officers, and other responders such as firefighters and EMS personnel is the immediate task. Once the scene is secured, an officer may provide aid to any person in need of immediate assistance until medical responders arrive. Typical first aid provided by officers is hemorrhage control by direct pressure or, more recently, with the use of tourniquets. With the scene secured and first aid provided, they must begin to determine the boundaries of the crime scene and secure it usually using crime-scene tape. Potential witnesses must be identified and secured in place. Physical evidence must be preserved and left undisturbed to allow a thorough investigation by other responding law enforcement, for example, detectives and evidence technicians. With these forensic responsibilities in mind, requests by police officers should generally be accommodated when such requests do not interfere with the immediate needs of a patient. If the request will delay important medical care or result in the potential deterioration of the patient's condition, the EMS provider should explain what expedited medical tasks must be done and how best to accomplish those tasks.  Cooperate with requests but advocate for the patient.[1][2][3][4]

Issues of Concern

When Should an EMS Provider Treat a Location as a Crime Scene?

Knowing when a location will be a crime scene will help EMS providers determine how to act. A crime scene is considered any location where a criminal act occurred or where evidence from a criminal act may be found. This includes but is not limited to violent acts, drug manufacturing, and fires. EMS providers should be careful to consider as crime scenes the location of runs that appear to be obvious or reported suicides or accidents. Reported self-inflicted or accidental injuries must be investigated by law enforcement to confirm these reports. These scenes should be treated like any other potential crime scene in terms of evidence preservation and documentation.[5][6][7][8]

What Are the Responsibilities of EMS?

Once personal and rescuer safety is established, EMS personnel must provide medical care to the sick and injured as their highest priority. When there is an associated crime scene, it is important to reach this goal with minimal disruption to possible evidence. Use one site for entrance and exit into the scene and document and take note of the details of the scene as best as possible. EMS should keep track of everything that they touch or disturb, and they must avoid moving anything that they do not need to move. If they do not need to touch or examine an item to provide appropriate medical care, then they leave the item undisturbed. In cases of death on the scene, only move the patient to the extent necessary to determine death. If the body must be moved or if clothing must be cut and removed, be sure to document this in the run report and inform the investigating officer on the scene. In some locales, documentation of asystole may be required to declare death. If the circumstances of the death and the condition of the body allow for the declaration of death without cardiac monitoring or documenting the absence of a pulse, then the body should not be touched at all.

Evidence Collection

It is very unusual that an EMS provider would need to remove an item of potential evidence from a scene to provide optimal care. Medication bottles or a medication list maybe some of the few such items.  Weapons, shell casings, or personal clothing items are never valuable to the treating providers and should never be transported. If one must remove something from the scene, then they should place it in a brown paper bag. If the item is saturated in liquid, then the item is placed in the paper bag, and then the paper bag is put in a plastic bag. Articles of clothing containing evidence are frequently transported as full exposure of the patient does not occur until inside the ambulance or the emergency department. When removing the clothing from victims of violence, care should be taken not to cut through bullet holes or knife holes. Likewise, EMS should avoid cutting through bloody or contaminated areas of the clothing, cutting instead through clean areas. Note in the run report (medical record) the method of clothing removal and the location of any cuts made (e.g., "the sweatshirt and shirt were removed by cutting up each of the sides including the sleeves").  Removed clothing should be placed in a paper bag, in a clean plastic bag (not a biohazard bag that may contain biohazard from another run), or on a clean sheet and saved for law enforcement. When caring for a victim of an alleged sexual assault, minimize clothing removal and potential contamination of the clothing. Do not clean any skin except as needed for direct patient care. Forensic sexual assault examiners may need to collect potential evidence from the patient's face, fingers, nails, or any site that might contain DNA evidence.

Documentation

EMS professionals should document and observe the setting of the scene. If the nature of the run is dispatched as a potential crime scene, EMS should always wait for police officers to arrive on the scene and declare it safe for medical responders. If an EMS professional is the first person to arrive and unexpectedly discover a possible crime scene, they may have important knowledge of how the crime scene looked. They should take note of signs of forced entry, positions of bodies, lighting, and any open doors. Blood and bloody footprints can be significant evidence in an investigation. Avoid stepping in blood or other fluids whenever possible. Documentation should be free of any opinion and state the facts. If the patient is a victim of a crime, it can be very helpful if providers document victim statements accurately and precisely.  Using quotation marks, document exactly what the patient says happened. Likewise, document exactly what witnesses say happened. These quotes can assist law enforcement in their investigation and possible prosecution at a later time. Statements that may not seem relevant or important at the time may later prove to be very valuable.  Victims of domestic violence may speak freely immediately after the incident, telling details of how the injuries occurred and who inflicted the injuries. Often, however, these victims may be reluctant to testify against the perpetrator for fear of retaliation.

Clinical Significance

Knowledge of optimal procedures and documentation of findings at crime scenes may not directly impact clinical outcomes. Such knowledge is, however, very important for ensuring that the patient's interest in the criminal justice system is protected. Successful prosecution of potential violent crimes may be significantly impacted by the manner in which medical personnel provides and document the medical care. Ultimate outcomes in the criminal justice system can be an important factor for victims emotional recovery.[9]

References

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Benomran FA. The medico-legal scene in Dubai: 2002-2007. J Forensic Leg Med. 2009 Aug;16(6):332-7. [PubMed: 19573843]

Putkonen H, Weizmann-Henelius G, Lindberg N, Eronen M, Häkkänen H. Differences between homicide and filicide offenders; results of a nationwide register-based case-control study. BMC Psychiatry. 2009 May 29;9:27. [PMC free article: PMC2694780] [PubMed: 19480648]

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What is the purpose of the narrative section of the patient care report?

What pertinent information should be obtained on a patient care report?

What would be considered an objective patient assessment finding?

What is an example of improper documentation on a patient care report?