EMS Documentation


Introduction

The prehospital care report form, for most services, records demographic data (name, address, billing information), vital signs (Glasgow Coma Scale, blood pressure, pulse and respiration rates, pain), a patient assessment, and details of any interventions that the emergency medical services (EMS) provider performed. The care report form can be on paper, electronic device (the ePCR), or sometimes a combination of both.  Prehospital care report forms provide the details of patient care for handoff to other healthcare providers. The prehospital report also provides the documentation necessary for ambulance coders to create a bill to reimburse for treatment provided.  Prehospital report forms are used in legal investigations, trauma registries, CPR registries, research, and quality improvement initiatives.[1][2][3][4][5]

Issues of Concern

Data

The prehospital care report is used to record patient data. The data can include patient demographics such as name, address, date of birth, age, and gender.  Dispatch data, such as the location of the call, times related to the call, rescuers and first responders on the scene may be included. The report should document 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.  All U.S. states require documentation of 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 treatments. Failure to record this information can result in disciplinary action from regulatory bodies.[6][7][8][9]

Initial Impression

EMS providers can provide details on the mechanism of injury, which can help guide treatment when patient care is transitioned on arrival to the hospital.[1] Mechanism of injury can provide information for the proper identification of injury patterns. For instance, in a motor vehicle collision noting the degree of occupant compartment intrusion and whether safety devices were used or triggered,  can help quantify the extent of injury expected.

Documentation of the initial EMS impressions provides an overall impression of the patient’s status at the time of scene arrival.  Patient response to treatment, whether improvement or deterioration in status during transport, can be better appreciated when compared to initial impression.  Failure to document initial findings has been correlated with poorer patient outcomes.[2]

Assessment

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

Emergency medical service education emphasizes the importance of students first assess scene safety.  Scene safety is paramount, and EMS providers must wait until the scene is determined to be safe before entering the area and beginning patient care.[3]  Airway, breathing, and circulation should be assessed first and the immediate life threats addressed. A quick head to toe evaluation and assessment is often performed.  After the initial assessment, EMS providers should complete a more focused exam related to the patient’s chief complaint. If each of the initial assessment and focused examination is adequately documented, a more complete picture is provided to billing staff, quality assurance and improvement committees, and most importantly to other care providers.

Vital Signs

The vital signs that should be documented are:

  • Pulse (including the quality and quantity)
  • Respirations (including the quality and quantity)
  • Blood pressure
  • Pulse oximetry
  • Glasgow Coma Scale
  • Pain level/scale

Trending vital signs can help providers track patient improvements or recognize the need for further intervention for worsening conditions. 

Interventions

Each intervention performed by EMS providers, as well as the rationale for the intervention was performed, must be adequately documented. Clear documentation helps prevent unnecessary duplication of treatment and patient harm.[4]   Medicare will only pay for interventions that are medically necessary. Without the correct information, documentation, and a clear rationale for a given intervention, the procedure or treatment may not be reimbursed. 

Uses for Prehospital Documentation

The primary purpose of EMS documentation is to provide a written record of patient assessment and treatment that can help guide further care.  For the information to be readily understood and communicated, it must be organized in a format that all healthcare providers involved in patient care will understand.  A common language and terms that are readily understood by all parties must be used. To minimize the chance for confusion, medical errors, and misunderstanding, care must be taken to ensure that profession-specific language and jargon and uncommon abbreviations are avoided.  The communication style can unintentionally undermine a readers’ ability to find 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 and emphasize the importance that documentation should ensure effective communication.

Prehospital documentation is used for different purposes.  Information should be written in a clear, concise way so other healthcare professionals can easily understand the information.  Frequently, other healthcare providers will skim the narrative, looking for keywords to help them understand the information.   The ability to skim a document is hampered when there are more pros and narrative used.[4]  A mnemonic commonly used to organize patient charting is SOAP (subjective, objective, assessment, and plan).  When the SOAP format is used,  the chart is documented in the order from subjective complaints, objective findings, assessment notes, and plan of action.  While other documentation formats may exist, the SOAP structure is commonly used since it allows for easy access to information.

Billing

Bills to reimburse the service for patient care and transport are generated from the prehospital documentation.  The more detailed the documentation, the more accurate the bill generated.  Billing personnel use prehospital records to determine the level of care (BLS, ALS1, ALS2, or SCT) and to generate and refine ICD-10 coding for the chart. The level of documentation is very important for billing. To document a call as ALS1 versus ALS2 is based partially on the number of interventions.  The quality of documentation directly affects reimbursement rates and revenue generation for the department.

Handoff

Accurate, complete, and easy-to-read documentation can assist in the continuity of care plan and treatment.  While many prefer a verbal transfer of information, the verbal report is not a substitute for proper written documentation. W hile conversations and details on the patient may fade with time, the written document does not, even in a busy, fast-paced environment such as an emergency department or intensive care unit.[4]

Data Tracking and Research

Multiple agencies use information from the prehospital record and EMS calls to track trauma and CPR survival.  In Texas, the EMS and trauma registries consist of 5 separate registries: EMS registry; Traumatic Brain Injury Registry; Spinal Cord Injury Registry; Submersion Registry; and other Acute Traumatic Injury Registry.  Nationally, the NEMSIS project collects data to help improve practice guidelines through evidenced-based research.  Ongoing data collection and analysis facilitates standardization of care across the nation and allows for planning for future EMS growth.  Emory University partnered with the United States Centers for Disease Control and Prevention (CDC) to create the cardiac arrest registry (CARES). The goal of CARES is to increase cardiac arrest survival rates.  CARES collects part of its data from EMS documentation.  

Quality Assurance/Improvement

Quality assurance and improvement efforts vary depending on the organization.  EMS prehospital documentation is used to review how patients are being treated and assess how out-of-hospital providers adhere to common practice guidelines and protocols.  Accurate documentation of patient interaction and care is necessary for the success of quality assurance and improvement initiatives.  Poor documentation can limit what is learned from the prehospital record.   Without appropriate documentation, quality assurance and improvement mechanisms may have difficulty assessing the quality of care.  Depending on the service and state, this could 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 EMS provider needing to defend their actions. When an EMS provider is called to testify, complete and accurate documentation can help to defend the provider and may help trigger memories of the patient encounter many years later.  Properly documenting statements made by the patient, bystanders, relatives, and other healthcare providers can also decrease culpability when there is an adverse event.[4]  Complete and correct documentation will help the EMS provider appear more competent when reviewed by lawyers or regulating bodies.  Some states, such as Texas, can revoke an EMS provider's license if documentation fails to meet state standards.[6]  It is often quoted that the “faintest ink is more legible than the best memory.”[7]

Clinical Significance

Prehospital care reports and records of patient encounters can be organized in many different formats, but the information is vitally important for many aspects of patient care beyond the scene.  The EMS record should include the patient’s demographics, vital signs, assessment, and information on any interventions performed. The documentation serves an important role as a data repository.  The information can be used to create a bill, to facilitate communication and transitions of care, to track compliance, guide quality initiatives and represent the EMS and other healthcare providers in legal matters.  Without excellent documentation, it is difficult to show excellent care.


Article Details

Article Author

Matthew Short

Article Editor:

Scott Goldstein

Updated:

9/25/2020 3:27:04 PM

PubMed Link:

EMS Documentation

References

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