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Disaster Documentation for the Clinician

Published online by Cambridge University Press:  25 July 2013

Richard M. Zoraster  and
Christopher M. Burkle
Richard M. Zoraster*
Affiliation:
Los Angeles County Emergency Medical Services Agency, Los Angeles, California and University of Hawai'i Office of Public Health Studies, John A. Burns School of Medicine, USA
Christopher M. Burkle
Affiliation:
Department of Anesthesiology, Mayo Clinic, Rochester, Minnesota, USA
*
Address correspondence and reprint requests to Richard M. Zoraster, MD, MPH, Los Angeles County Emergency Medical Services Agency, 1011 Pioneer Blvd, Ste 200, Santa Fe Springs, CA 90670 (e-mail [email protected]).
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Abstract

Documentation of the patient encounter is a traditional component of health care practice, a requirement of various regulatory agencies and hospital oversight committees, and a necessity for reimbursement. A disaster may create unexpected challenges to documentation. If patient volume and acuity overwhelm health care providers, what is the acceptable appropriate documentation? If alterations in scope of practice and environmental or resource limitations occur, to what degree should this be documented? The conflicts arising from allocation of limited resources create unfamiliar situations in which patient competition becomes a component of the medical decision making; should that be documented, and, if so, how?

In addition to these challenges, ever-present liability worries are compounded by controversies over the standards to which health care providers will be held. Little guidance is available on how or what to document. We conducted a search of the literature and found no appropriate references for disaster documentation, and no guidelines from professional organizations. We review here the challenges affecting documentation during disasters and provide a rationale for specific patient care documentation that avoids regulatory and legal pitfalls. (Disaster Med Public Health Preparedness. 2013;0:1–7)

Keywords

DisasterDocumentationMedical recordLiabilityInformed consent
Type
Special Focus
Information
Disaster Medicine and Public Health Preparedness , Volume 7 , Issue 4 , August 2013 , pp. 354 - 360
Copyright
Copyright © Society for Disaster Medicine and Public Health, Inc. This is a work of the U.S. Government and is not subject to copyright protection in the United States. 2013 

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