“If You Didn’t Write It On Your Patient Care Report, You Didn’t Do It.”
The patient care report (PCR) is an essential document that conveys prehospital patient and demographic data to the emergency department or other hospital-based healthcare provider. Even as paramedics respond to emergency calls and provide emergency care on route to the hospital, they need to ensure accurate and timely prehospital PCRs for the emergency physician. The emergency department can make further treatment decisions based on the outcomes of treatments noted on the PCR. The best way for paramedics to ensure clear, complete, precise, and timely patient care reports is to rely on an experienced medical transcription service provider.
Purpose of the Prehospital Patient Care Record
- To serve as a medical record
- To provide a precise picture of the events that occurred
- To ensure standards of care were met
- For quality assurance and performance improvement
- To bill government and private insurance
- For use in litigation
There are different PCR formats and special reports would be needed for disasters. Paramedics should use the format specific to their organization’s needs and provide a comprehensive and pertinent account of the events leading up to the patient handover to the hospital.
Importance of Accurate and Timely Prehospital PCRs
By documenting their initial assessment, the paramedic provides an overall picture of the patient’s status at the time of their arrival on the scene. This initial evaluation of the patient helps support the medical diagnosis and basis for treatment decisions. In addition to documenting the assessment, each intervention performed by the paramedic and the rationale for it should be properly documented.
The information should be clear and concise documented so that the emergency physician and other healthcare professionals can easily understand it. Accurate, complete, and easy-to-read documentation can help guide the care plan and further treatment. Detailed and accurate prehospital documentation is also necessary to secure reimbursement the patient care services and transport to the hospital. Also, if an EMS provider is called to testify in a court of law, complete and accurate documentation can help to defend the provider.
Prehospital PCRs – Problems Reported
While it is an essential tool for ED handovers, many problems have been reported with prehospital PCRs. A 2015 report in the Journal of Emergency Medical Services (JEMS) references John Riccio, MD Medical director for South Metro Fire/Rescue in Centennial, Colorado, as saying that while he was sure that paramedics were providing proper care, a review of the PCRs they created were rife with problems. To quote from the article, “Treatments were entered out of order, some narratives offered only a brief paragraph, and assessments were so full of abbreviations that the reader needed a medical dictionary to understand them. Misspelled words and poor grammar made even smart paramedics look bad, but the problem wasn’t just mistakes by the crew. A lot of the difficulty came from the format of the reports; important information was often buried in long lists, but not included in the narratives where most healthcare professionals put them.”
Studies on PCRs have also reported many concerns. A study published in the West J Emerg Med. in 2013 reported that most electronic prehospital PCRs were not available at the time of ED medical decision-making. Further, though handwritten prehospital PCRs were more readily accessible, they had legibility and accuracy concerns.
Medical Transcription Services to the Rescue
The reports that a medical transcription company provides from physician dictation include consultation reports, client medical history reports, physical exam reports, emergency room reports, operative reports, laboratory reports, radiology reports, pathology reports, and discharge reports. They can also provide transcripts of dictated prehospitalization reports. The JEMS article reported how paramedics benefited from medical transcription. South Metro experimented with U.S. based medical transcription services to document their paramedics’ dictation and found that it considerably improved the accuracy and timeliness of prehospitalization PCRs.
The information in a prehospital patient care report generated by a medical transcriptionist would generally include the following:
- Patient demographics (name, address, date of birth, age, and gender)
- The location of the call and time of the call
- Names of rescuers and first responders on the scene
- Data related to patient care related data – patient’s chief complaint, provider’s initial impression of the patient, evaluation, status and vital signs of the patient during ambulance transport, interventions done, and responses to those treatments
Outsourcing medical transcription can also help the paramedic clearly communicate the message to the emergency physician. According to ems.com, paramedics should ensure:
- Legible documentation with no spelling errors
- Use only approved medical abbreviations
- Double-check demographic data
- Use a consistent system to track time and document travel times, treatment times, and changes in condition
- Document what they see and hear (and smell, if necessary) throughout the call
- Report statements made by others about what happened prior to their arrival.
- Provide a detailed chronological narrative of the call from the beginning to emergency room.
Good documentation takes time and paramedics may find it difficult to find that time. With professional medical transcription services to assist them, paramedics can ensure highly accurate reports every time.