Documentation improvement practices are vital to our profession and the patients under our care. Most would agree this topic doesn't get the "airtime" it deserves. After all, while it's not the most glamorous topic, documentation of our service calls is required by law, these are legal documents - you can't escape from writing/completing these reports. EMS documentation is both a form of qualitative (narrative) and quantitative (vitals, GCS) data. Data, now more than ever, is the currency of healthcare. Excellent clinical documentation and continuous enhancement of our skills in this area can help maximize claims, reimbursement revenue, and most importantly improve care quality.
You could be the most technically skilled/savvy EMS provider out there and you could deliver excellent patient care, but if your reports leave more to be desired, you may soon face a predicament that becomes uncomfortable.
When completing your electronic patient care reports (ePCR's), consider the audience.... pro-tip - the audience is multifaceted and includes many stakeholders who have different objectives. You carefully craft this documentation after every encounter to:
Communicate with other health care professionals (ED clinicians, STEMI coordinator, stroke teams, another EMS entity).
Inform billing companies - could be 3rd party (it's certainly important to your agency). The level of reimbursement is greatly tied to the quality of your report.
Mount a legal defense should a particular call go to court (it may be 10+ years after the incident) - Your ePCR will serve you well --- your memory and recollection of events will most certainly fail you -- especially under the stress of the courtroom lights. We are quite a litigious society - protect yourself with thorough and objective documentation.
Participate in QA/QI programs -- this is crucial for research and has arguably the greatest impact on improving future patient outcomes.
Remember, as first responders, you were likely the only group who "had eyes on the scene", those details have to be shared during the transfer of care. That narrative could go a long way in how the patient gets ultimately gets treated and can heavily influence treatment modalities. Face it many times the physicians miss your bedside handoffs. Knowing that, clinicians in the hospital (especially in the critical care units) are reading your reports more than you realize. Personally, I've had a cardiac arrythmia patient avoid a costly invasive procedure because I was able to capture a tachydysrhythmia. This rhythm, no matter how hard they tried could not be re-created in the hospital setting. Hard to put a price tag on that story.
Lastly, keep in mind that comprehensive and accurate documentation should be a team sport. The same could be said of robust quality assurance and quality improvement programs (QA/QI). Regular conversations should commence, and the agency medical directors should be intimately involved from the beginning. Documentation should be completed in a timely manner. QA/QI when things take an unexpected turn or when things go correctly should also be done in a timely manner. The goals of these programs are simply to:
Hold colleagues accountable while promoting a non-punitive culture.
Clearly articulate what you want to IMPROVE/FIX/AVOID.
Define both primary and secondary drivers that come back to the overall aim.
Carefully plan out corrective actions.
Gather clinical outcome/disposition data from your local hospitals/health systems. {This can be done in an automated fashion}
Not focus on just the outliers or "The bad".
Scrutinize "the wins" as much as the shortfalls.
Embrace the PLAN-DO-STUDY-ACT cycle - that wheel never stops moving.
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