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Electronic Patient Care Report Documentation Pitfalls and How to Avoid Them

by Steve Sweeney on November 15, 2017 at 12:19 PM


Writing patient care reports for those they have treated has been a requirement of paramedics and EMTs for years. As such, paramedics and EMTs were taught during their initial schooling that writing a report was necessary to protect themselves from potential liability that may occur from their actions or perceived lack of actions, a record of what exactly transpired between themselves and the patient.

There was also the transfer of care component: the run record was kept as part of the patient’s medical records, indicated the various treatments and actions performed during EMS contact time and served as part of the overall treatment plan for the patient’s complaints. Finally, the documentation of the patient care report was necessary if an agency was seeking reimbursement for their services provided from Medicare, Medicaid and commercial insurance companies. Whether enjoyable to complete or not, the patient care report documentation was and continues to be a necessary aspect of a Paramedic or EMT’s daily job duties.

Over the years, the demand for better or certain types of documentation have continually increased. In the beginning, report writing oftentimes consisted of multiple handwritten documents that came together to form a patient care report. Paramedics and EMTs longed for the day of an easier solution to this requirement as some crews would run multiple calls a shift and the time required for crews to complete paper reports could equal hours. The birth of the electronic patient care report (ePCR) on laptops, PCs and tablets seemed to be the answer that everyone had long been waiting for.

Related: Explore strategic ways to improve your EMS agency's process and patient care report documentation for inter-facility and other non-emergency transports.

Within the last decade, the use of the ePCR has become commonplace amongst agencies and proven, in most cases, to be the answer everyone had hoped for in terms of patient care report documentation. But while the various ePCR software solutions on the market today have helped with documentation and various other tasks such as state reporting, ease of transmitting or providing reports to facilities and tracking such things as medications provided and interventions performed by crews, some pitfalls have emerged from the use of the ePCR. In analyzing these pitfalls, not only can a better understanding of them be gained, but a means to help avoid such pitfalls can be formed so that more complete and accurate documentation can result.

Ineffective Drop-down Menus

The use of drop-down menus provide crews with various different responses to select from for key data points and can save time for members completing reports. However, any drop-down’s selection list is only truly helpful if the correct choice is actually available in the list. If not listed, the response must be included in the narrative for proper documentation and follow-up with supervisors to determine if the response can be added to the list for future use.

Too many times, unfortunately, neither of these occur. As a result, a potentially important piece of the documentation may or may not actually end up in the narrative and the list will not be updated to reflect the most pertinent options.

To avoid this pitfall, ensure that all drop-down lists are updated as much as possible with appropriate choices. Further, keep in mind that the drop-down list can actually slow a paramedic or EMT down if the list of possible responses is too long to search through.

Poorly Used Narrative Templates

One of the most innovative solutions that emerged with the use of the ePCR was the auto-generated narrative, of which was seen as a solution to a Paramedic or EMT having to write a narrative from scratch. Using a pre-generated template and inputting responses provided through the use of the drop-down fields, a complete narrative could be generated. While once seemingly the answer to everyone’s dreams, these narrative templates came with several pitfalls.

First, unless you have multiple well-designed templates to choose from based on the patient complaint, your narrative may sound robotic and, oftentimes, lack crucial details that a coder coding your report needs. Therefore, make sure the narrative starts with a good foundation. This may require human intervention, requiring providers to edit the generated report, fill in any blanks and add details that the drop-down fields failed to capture.

Frequently, crews forget that a good foundation is needed and simply leave the auto-generated narrative as is, assuming it has done its job. Unfortunately, this auto-generated narrative frequently lacks detailed information. For example, is it possible from a drop-down menu to list all the various different answers or responses that the patient, family or others may have provided to a Paramedic regarding the history of the patient’s present illness? Could you imagine how long that list would be if it accounted for every variable? It would be virtually impossible for this to occur, which means human intervention is needed to edit the narrative with specifics.

Due to the many pitfalls associated with auto-generated narrative templates, many agencies have turned off this feature in their ePCR solutions and now require crews to manually write their narratives. To ensure crews generate quality patient care report documentation, either eliminate this feature as well or, alternatively, ensure crews are editing and adding supplemental documentation to any auto-generated narratives.

Inaccurate Defaults

The use of defaulted answers in the ePCR software can be another significant time saver for crews. For example, the GCS field may be set to default to 15, Pupils to PERRL, Lung Sounds to Clear and Equal. Defaults can also help with documenting head to toe assessment results by defaulting all fields to WNL or No Abnormalities Noted.

While defaults can clearly save time, a different kind of issue has evolved from this feature. Often, crews forget to go back and change these defaulted field answers and then end up with conflicting information in a report. For example, in the vitals section the patient is indicated as having a GCS of 15, yet the narrative states the patient is acting confused. In other instances, an assessment may indicate the patient moves all extremities (WNL), yet in the narrative the patient is documented as having a possible hip fracture and cannot move the leg. Which is the correct status of the patient? Any person reading a report at a later date would not be able to determine which is correct. An issue such as this with documentation, when discovered, can lead an auditor to question the overall accuracy of the patient care report and, in some cases, the true status of the patient being evaluated and treated.

Unfortunately, we have seen far too many times where conflicting data due to defaults has resulted in a need for an addendum and, as a result, a delay in filing, a denial for a claim or a request to have payments refunded—simply because of an oversight or honest mistake by the Paramedic or EMT.

Another commonly seen issue with defaults relates to responses that are all defaulted to Normal in the assessment fields of the software. Consider this: what are normal lung sounds for the COPD patient currently being evaluated for a complaint versus the next patient that doesn’t have COPD? Documenting the actual findings such as Diminished or Clear and Equal is more appropriate than leaving the assessment field noted as Normal.

To address defaults, particularly those that populate with Normal, your agency’s treatment protocols should clearly indicate what is considered “normal” for a patient’s individual assessment finding in case you may be challenged legally during possible future litigation. Further, you’ll want to ensure crews are going back to review their patient care reports to determine if those pre-answered assessment fields make sense and match what was actually written in the narrative.

ePCR solutions are here to stay, and they can be extremely helpful. However, agencies and their crews must ensure that they are using these electronic records properly in order to produce the ultimate documentation goal of C3A: Clear, Concise, Complete and Accurate documentation.

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This post was written by Steve Sweeney

Steve Sweeney is a director at Intermedix. He has 25 years of experience in the fire/EMS industry. Prior to joining Intermedix, Steve had six years of EMS billing experience including four years of managing the day-to-day billing operations for a 911 EMS agency.