EMS, Documentation

Article Author:
Matthew Short
Article Editor:
Scott Goldstein
Updated:
10/27/2018 12:32:01 PM
PubMed Link:
EMS, Documentation

Introduction

The prehospital care report for most services consists of a form for recording demographic data (name, address, billing information), jotting down vital signs (Glasgow Coma Scale, blood pressure, pulse and respiration rates, pain), documenting an assessment, and recording any interventions that the emergency medical services provider may perform during their care of a patient. Sometimes the form is paper, sometimes an electronic device (the ePCR), and sometimes both. It is on these forms that patient care is recorded for handoff to other healthcare providers. Ambulance coders can create a bill to submit to the payors for reimbursement, and the forms are also used in legal investigations, trauma registries, CPR registries, research, and quality improvement initiatives.

Issues of Concern

Data

The prehospital care report is a tool used to record patient data. The data can include patient demographics such as name, address, date of birth, age, and gender. It can also include dispatch data such as the location of the call, times related to the call, rescuers and first responders on the scene. The report is also vital in documenting patient care related data points, such as the patient’s chief complaint, provider’s initial impression of the patient, assessment, trending vital signs throughout the transport, interventions performed on the patient, and the results of those interventions. In all states, appropriate documentation is required, including documenting the patient’s initial condition, the care provided by first responders and EMS providers, the status of the patient during the ambulance transport and responses to any treatment. Failure to record this information can result in disciplinary action from regulating bodies.

Initial Impression

Since the EMS providers often see the scene, describing the mechanism of injury is vitally important to other care providers upon patient handoff at the hospital.(1) Mechanism of injury can provide information for the identification of injury patterns. For instance, in a motor vehicle collision noting occupant compartment intrusion and use of safety devices can help identify the extent of injury expected from the patients involved.

Initial impression also paints a picture of the patient’s status when the emergency management service provider arrives on the scene. For instance, seeing a patient in respiratory distress, sitting in a tripod position with cyanosis around his lips, compared to the patient that arrives at the hospital in the ambulance who is pink with improved breath sounds, after receiving nebulized medication. The initial impression can help hospital staff know the extent of the initial respiratory distress compared to the patient who is receiving treatment. Failure to document initial findings has been correlated with poorer patient outcomes. (2)

Assessment

The assessment of a patient, especially the initial assessment, helps to support the medical diagnosis, rationale for treatment decisions, and guidance for protocol adherence. Failure to document the assessment can lead to questions regarding appropriate care.

During primary emergency medical service education, students are instructed first to assess the scene. Scene safety for the emergency medical personnel is paramount. Until the scene is determined safe, the emergency medical service provider must wait. (3) Once hands can be placed on the patient, a quick assessment of the patient’s airway, the quality of breathing, and the quality of circulation is obtained to correct immediate life threats. A quick assessment from head to toe is often made. This is followed by a more focused exam related to the patient’s chief complaint. If each of these steps is documented, a complete picture is provided to billing staff, quality assurance and improvement committees, and most importantly to other care providers.

Vital Signs

The vital signs of pulse (including the quality and quantity), respirations (including the quality and quantity), blood pressure, pulse oximetry, Glasgow Coma Scale, and pain are all necessary pieces of data to paint the picture of the patient’s status. Trending patterns can be recognized to illustrate patient improvements or worsening of conditions.

Interventions

The interventions, as well as the rationale for the interventions performed by emergency medical service providers, must be adequately documented. This prevents potential repetition and patient harm. (4) In addition, Medicare will only pay for interventions that are medically necessary. Without the documentation and clear rationale painting the picture that the intervention was indeed necessary, there could be no reimbursement.

Uses

The primary purpose of documentation is to provide a written avenue of communication within a healthcare team. For communication to occur, it must be provided in a way that both the giver and receiver of the information can understand. The language must be common to both the writer and reader to connect. Because of this, care must be taken to ensure that profession-specific language, jargon, and uncommon abbreviations are not used. Use of this style of communication can undermine the readers’ abilities to find and use the information they need. (4) The Institute for Safe Medication Practices (ISMP) and The Joint Commission have a list of dangerous abbreviations, acronyms and other symbols emphasizing the fact that care needs to be made in documentation to ensure effective written communication.

Since the documentation is used for different purposes by different people, it is recommended to write in a clear, concise way so that other healthcare professionals can easily ascertain the needed information. All too often other providers skim the narrative, looking for key words. This is hampered in a more narrative or prose style of writing. (4) One commonly used mnemonic for patient charting is SOAP, meaning that one should chart subjective complaints, objective findings, assessment notes, and the plan of action. While other formats may exist, this commonly used method allows for quick access to pertinent information for other busy healthcare providers.

Billing

The billing personnel use the documentation provided by the emergency management service providers to generate a bill for the transport. The more detailed the documentation, the more accurate a bill can be generated. From the documentation, the billing personnel can determine the level of care (BLS, ALS1, ALS2 or SCT) and more effectively implement the ICD-10 coding. For instance, to document a call as ALS1 versus ALS2 is based partially on the number of interventions. This directly affects reimbursement rates and revenue generation for the department.

Handoff

Accurate, complete, and easy-to-read documentation can assist in informational continuity. While many prefer a verbal transfer of information, the verbal report is not a substitute for proper documentation. While conversations and memories of the patient contact may fade with time, the written documentation typically does not, even in a busy, fast-paced environment like an emergency department or intensive care unit. (4)

Data tracking and Research

Multiple agencies follow information from emergency management service calls to track trauma and CPR survival. In Texas, the EMS and trauma registries consist of 5 separate registries: emergency management service registry; Traumatic Brain Injury Registry; Spinal Cord Injury Registry; Submersion Registry; and other Acute Traumatic Injury Registry. Nationally, the NEMSIS project collects data.The data is then used to create better practice guidelines through evidenced-based research. This helps to facilitate standardized care across the nation and allows for planning for future emergency management service growth. Emory University has partnered with the United States Centers for Disease Control and Prevention (CDC) to create a cardiac arrest registry (CARES). The goal is to increase cardiac arrest survival rates through data. Some of that data is received through emergency management service documentation. Whether local, state, or national, research is ongoing to ensure excellence in care regardless of location. Quality in documentation is required for appropriate data collection. 

Quality Assurance/Quality Improvement

Quality assurance and quality improvement efforts vary from organization to organization. From case reviews with medical directors to state medical board reviews, emergency management service documentation is used to review how patients are being treated and how out-of-hospital providers are adhering to common practice and protocols. Accurately documenting the patient interaction is necessary for these initiatives, and without quality documentation, these initiatives suffer. Also, learning from the patient care interaction is hampered by poor documentation. While excellent care can be provided, without appropriate documentation, the quality assurance and quality improvement committee may have a difficult time seeing the excellent care. Depending on the service and state, this can lead to suspension from duties or loss of certification and licensure.

Legal

Prehospital care reports are also used by courts. Having an incomplete or flawed report can increase the chances of the emergency management service provider defending their actions. When an emergency management service provider is called to testify, having complete and accurate documentation can help to defend the provider because it may trigger memories of the patient contact many years later. Properly documenting statements made by the patient, bystanders, relatives, and other healthcare providers can also decrease culpability in the case of an adverse event. (4) In addition, having complete and correct documentation will help the emergency management service provider appear more competent when under review by lawyers and regulating bodies. Some states, Texas, for example, can revoke emergency management service provider licenses if their documentation fails to meet state standards. (6) It has often been said in many different circles that the “faintest ink is more legible than the best memory.” (7)

Clinical Significance

While the prehospital care report can take many forms, professionals must gather basic data including the patient’s demographics, vital signs and assessment of the patient, and any interventions performed on the patient. This data is then used to create a bill, to communicate, to track data, to assure and improve the quality of care, and to reference in legal matters. Excellent documentation is excellent care.