3 steps to properly documenting patient care in EMS

All members of the EMS team must commit to improving patient care documentation by expanding on the details and ensuring completion

By Steve Johnson

When asked by clients to review crew documentation to assist in their compliance efforts, we consistently find opportunities for improvement. It seems that too many crew members either don’t properly understand the requirements for compliant documentation, or worse yet – may not care. Clearly, the latter is a huge compliance risk that should not be tolerated, and fostering a culture of compliance can help deal with that fundamental problem.

All members of the team – from leadership to field crews – need to be committed to improving the quality of patient care documentation. Here are three things that we believe need to be better understood to aid in this improvement process.

For some, ePCR software has become an enabler of a natural human tendency toward laziness. (Photo/Omni EMS Billing)

1. The PCR is not a patient care outline

EMTs and paramedics are required to complete a patient care report for each patient encounter. Merriam-Webster defines report as “a usually detailed account or statement.”[1] Notice the word “detailed” in that definition.

Medicare contractors have stated that for a transport to be a covered service, the PCR must include a detailed description of the patient’s condition at the time of transport. More specifically, the PCR must include “an objective description of the patient's physical condition in sufficient detail to demonstrate that the patient’s condition or functional status at the time of transport meets Medicare limitation of coverage for ambulance services.”[2]

Far too often, the PCRs we review are better described as merely an outline of events and the patient’s condition. They often lack the specifics of the detailed report required for proper documentation of the patient care. In middle school, we all learned the difference between the outline and the actual report that stems from that outline.

2. Electronic patient care reporting software assists with the outline

In some ways, it seems that one of the unfortunate and unintended consequences of the growth of electronic patient care report software has actually been a deterioration, rather than an improvement, in the overall quality of patient care reports. ePCR software is a great tool that is often not being properly used to the fullest extent for the greatest benefit to the patient and the EMS organization.

For some, ePCR software has become an enabler of a natural human tendency toward laziness. As an example, we have had organizations ask whether a narrative is really necessary on a PCR, or whether that narrative could be eliminated altogether, now that they are using ePCR software.

ePCR software provides the opportunity to consistently track and report on a significant number of data elements, through a series of drop-down lists and checkboxes. However, it is important to clearly understand the difference between data and clear, thorough and detailed documentation of the patient’s condition, the care they received and their response to that care. Data elements provide bullet points (i.e., the outline), they do not paint the picture necessary for a detailed patient care report.

3. EMS crew members must complete the patient care report

While drop-down lists and checkboxes are necessary for clean, consistent data collection and analysis, they often do not provide the solution to adequately describe the various nuances of an individual patient’s experience of that data element.

For example, think of a data field labeled “Chief Complaint.” While a given crew may transport several patients where the truthful answer to that question is chest pain, no two patients experienced that data element the same way.

It is imperative that the reader learn from the PCR all the details of that data element – how the patient describes the location and quality of the pain, its severity, whether it radiates anywhere else, what the patient was doing when it started, what exacerbates or mitigates the pain and other details specific to that patient situation.

A well-written patient care report will put the reader, regardless of their level of medical knowledge, in the ambulance with the patient. It will allow the reader to see it, hear it, feel it, smell it. You don’t get that from an outline.

Crews should see those ePCR drop-down lists and checkboxes as reminders of data elements that need to be expanded upon, and fully developed and documented in a clear chronological narrative. In other words, see the data elements of the ePCR as building blocks for your narrative, not as a replacement for it.

After writing the narrative, crews should review the data elements and ensure that each one of them is fully explained and easily understandable by any reader of the report. As they review each of those data elements, they should ask themselves, “What question could someone who was not here witnessing this patient encounter first-hand, possibly have about this particular aspect of my patient’s presentation, treatment and response to care?” And then, “Does my documentation fully address those questions?

So, once all of those drop-down lists and checkboxes are completed for a given patient encounter, in the words of our middle school and high school instructors, “You’ve completed your outline, now write your report.”

1. Merriam-Webster. Definition of report. Available at: www.merriam-webster.com/dictionary/report

2. Novitas LCD L34942

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