Ask many EMS providers, and they'll tell you documentation is one of the least favorite parts of their job. However, next to patient care, it is one of the most important things we do. Many providers do not appreciate the varied and critical purposes served by their patient care documentation. Some simply see their patient care reports (PCRs) as documents casually tossed aside or ignored at the emergency department, or evidence that "can and will be used against them" in a quality improvement review. A full appreciation for the importance of EMS documentation comes from a deeper understanding of its uses and applications in five critical areas: clinical, operational, legal, financial and compliance.
This article looks at these five purposes of documentation. Not all of these issues apply to every EMS provider. For instance, some providers work in systems that do not bill for their services, so the financial aspect of documentation may not apply. Nevertheless, EMS providers are likely to move between several jobs during their careers. Thorough documentation skills must be "portable," so you can remain marketable in the workplace.
Clinical: For the Record
First and foremost, EMS documentation serves a vital clinical purpose. It is the record of your assessment and care of patients. It becomes part of the patient's medical record, both at the receiving facility and within your EMS organization. EMS PCRs record the role EMS providers played in the continuum of care for that patient. An accurate record of the care provided in the field can play a critical role in the subsequent treatment of patients in an ED, trauma center or other receiving facility. An effective EMS chart informs subsequent caregivers of the patient's presenting signs and symptoms, the caregiver's assessment of the patient's condition, attempted EMS interventions, successful EMS interventions and the patient's response to those interventions.
Because PCRs are primarily clinical documents, it is important that EMS providers furnish their documentation to subsequent caregivers promptly and efficiently. For instance, ambulance crews may benefit from the information contained in the first-responder's PCR. Hospital EDs may benefit from the information in the ambulance PCR. A physical therapist providing subsequent rehabilitation to an injured patient during their recovery may benefit from seeing a complete clinical presentation of the patient's injury, from the time of the incident forward.
While it is not always possible to provide a copy of a completed PCR to the next level of provider at the time of service, information vital to that provider's assumption of care should be communicated. For instance, if a paramedic administers a medication while en route to the hospital, the ED physician needs to know that so as not to inadvertently overdose the patient on more of that medication, or inadvertently administer a drug that could negatively interact with one given in the field. In some states, EMS laws or regulations establish specific time frames, such as 24 hours, within which an ambulance service must provide a full PCR to the hospital. Check your state law for any such guidelines that apply to you.
EMS providers sometimes assert that their documentation is ignored by the hospital or the ED physician, and cite this as a reason to be less complete, accurate or timely in their documentation. While EMS providers may not always witness their PCRs being carefully reviewed by an emergency physician, they should be aware that their documentation becomes part of the patient's medical record and will be reviewed and scrutinized.