Most EMS leaders understand that providing clear, detailed, and secure ePCRs are an important part of both taking care of a patient and ensuring your agency stays compliant with government requirements. However, while EMS leaders may understand this, a common problem that many agencies face is that the rest of the crew may not truly grasp their importance. This can result in frequently inadequate patient care reports – either because they don’t understand how to properly document, or they’re just simply not putting in the effort. In the emergency response field, it’s imperative to produce accurate, high-quality documentation for every single patient encounter – and getting all members of the team on board with this is the key to success.
Here are several tips to help ensure your team is accurately completing and utilizing patient care reports:
1.) Educate Your Team
Reinforce the importance of ePCRs that are detailed and include a narrative that paints a complete picture of both the patient’s treatment and their response to treatment. Take the extra time to explain to your personnel why it’s so important to provide more than just a simple outline of events and the patient’s condition. Make sure your team understands a patient care report can have an impact on various other areas, such as:
- The quality of care the patient receives
- The decisions that other medical professionals make for the patient’s care long-term
- Billing and health insurance coverage
- Staying in compliance with security and regulatory requirements
- Protecting your department from potential future lawsuits
Communicate to your crew that it’s important to have a holistic mindset both with your immediate treatment and when considering the patient’s long-term care. Taking the time to educate your team so they understand the “why” can ensure they’re committed to providing high quality patient care documentation.
2.) Use a Reliable ePCR Platform
A robust, secure ePCR platform allows your agency to consistently provide quality patient care that complies with national and state reporting and HIPAA standards. Having reliable ePCR software can make reporting easier, quicker, and more accurate. It ensures that your reports are complete before you submit them, and gives administration a way to monitor and report upon the data. A good ePCR platform can help you quickly ascertain how many times your agency administered a certain medication or performed a specific procedure. This information can help you analyze how specific actions effect patient outcomes and help you understand how to improve patient care.
ePCR software is an extremely useful tool in EMS, but how well you utilize your software can have an impact on the quality of your patient care reports. It’s also important to remember that the data you can record and track with ePCR software must be considered as just one part of completing a detailed patient care report. Team members should be reminded that making the most of your software is extremely beneficial, but it’s not an excuse to get lazy. Putting in the effort to provide a detailed narrative is still vital.
3.) Have a Well-Defined QA Process
What steps does your organization have to ensure that the quality of your ePCRs meet not only NEMSIS standards, but also your agency’s standards? Good ePCR software will validate against both national and state standards, but there’s no substitute for a good internal workflow to ensure crews are writing top-notch ePCRs.
Common workflows include having company officers or battalion chief-level officers verify narrative quality, and also having the report writer get reviews and signatures from at least two department personal who were also on the call. Additionally, the report writer should have the ability to request a review for unique patients or for local studies so that those doing QA can quickly access reports. Lastly, it should be easy for external evaluators like your medical director, base hospital, or pre-hospital coordinator to review ePCRs and tie them to patient charting to ascertain patient outcomes.
4.) Dig Deep with Actionable Data
Many agencies don’t take advantage of all the practical applications and analysis that well-documented patient care can provide. Taking time to dig deeper into what the data actually says about your agency can lead to:
- Identifying training opportunities
- Finding areas that may need improvement
- Seeing new ways to work towards better patient outcomes
For example, your well-documented patient care reports will allow you to look at the cumulative numbers for how many times your team is getting IVs on the first stick or how often patients are intubated. You can watch for trends over time, to see what types of procedures are most commonly performed and if certain injuries are becoming more prevalent over time.
Furthermore, you can share this knowledge to help reduce risks and build strong relationships within your community. It can help improve response times by providing insight into where to position ambulances and where the community is most at risk. Sharing this data with hospitals can reduce the chance of wasting precious time and resources and help improve long-term patient outcomes.
Taking the time to educate your team on the “why” behind high quality patient care reports, using good ePCR software, having a well-defined QA process, and taking advantage of the data your agency obtains are all ways to ensure your team is doing its best to provide detailed patient care reports and making the most of the end result.