As most of my regular EMS readers know, I know work in the Quality Improvement part of EMS. The company I work for has a unique approach to the subject as we take an educational approach to working with our clients.
Unlike typical QI, we don’t do any finger wagging when we meet with a medic or EMT to discuss a call that has questions or from which an issue has arisen.
That extends to the first part of the process, which is the PCR review. Auditors are taught during their orientation to avoid pejorative words and phrases. They are instructed to take the review as an opportunity to point out issues and offer solutions.
During initial classes with the services field staff we spend a lot of time going over documentation. In general, EMS education on documentation is pretty poor. Paramedic students might get a couple of hours of classroom, EMTs get almost none. I don’t know of any programs that have their students write reports as part of the classroom experience.
We have found that the 4-5 hours we spend on documentation issues have a positive effect on documentation. In turn, that has a positive effect on patient care because the EMTs and medics put more thought into their documentation and thus more thought into what they are doing. We don’t want them to turn into “protocol monkeys” but knowing what’s in the protocols and why it’s there is part of the job.
One thing we don’t do is comment or score on spelling, punctuation, sentence structure, etc… We do suggest that the providers use SOAPIE or CHART formats as it gives a well defined structure to the reports.
I do mention that while we don’t score on those factors, we sometimes laugh at what we see.
Once the providers realize that those formats work well, reports improve and scores for both the individuals and the services improve.
Sometimes when doing a review (everyone that works for the company does reviews), I have to bite my figurative tongue at some of the things I read.
Then, there is this,
m1 dispatched to above location for a m pt with daphretic. u.o.a pt was alert x 3. pt was having a hard time walking around. nursing staff called ems. pt has a history of crones and anxiety. pt is not taking any meds for it. pt had this since he was 16. pt as no primary dr. pt was placed on our stretcher via Stand and pivot. pt was placed on the monitor and showed nsr. pt was soaked from head toe from sweat. pt has abd pain and he has not eating anything for a few days. pt bg was 132 mg/dl. iv was attempted but not started. 12 lead was unreadable pt was shaking. pt was transported to XXX. en route pt vitals were taken and noted. pt lungs were clear and heent was normal. u.o.a pt was taken to room 25 where verbal and written report was given to the nursing staff
This is supposed to be a medical report. I had to read it three times before I could figure out what was going on. Actually, that’s not true. I read it three times and STILL couldn’t figure out what was going on.
My comments started out “Spelling aside…” and went on to point out that this was a very confusing narrative. I also noted that the care appeared to be appropriate, but that it was very incomplete. Keep in mind that treatments and procedures are documented in a different section of the report, so that part was okay.
That being said, the narrative is the most important part of the report. The drop down lists can’t tell the whole story. The narrative has vital details and must be written clearly. This was a report fail. A total report fail.
I winced at the thought of a doctor, nurse, or billing coder reading this.
Many people in EMS pride themselves in the profession of EMS. That includes me, because I worked in one of few systems that has been determined by an independent arbiter to be staffed by professionals. I won’t go into the details as they aren’t germane to today’s subject, but the elements of EMS as practiced in my former agency met the legal definition of “profession”. As opposed to trade. Which EMS for the most part isn’t either.
For the most part, EMS is a skill set. Some people do EMS full time and it’s their agency’s sole function. Others are fire departments or police departments that also do EMS. Or something else that also does EMS.
If you consider EMS a profession and yourself a professional, then you want to look and act the part. Clear, accurate documentation is part of that. The narrative above does not present the author as a professional. I don’t know what it does present the author as, but I can’t think of it as anything other than a person who writes a sloppy report. By extension, a sloppy report represents sloppy care.
I remember a police case from some years back. The officer who wrote that report also did a sloppy job. When it went to trial, defense counsel tore the report and by extension the work of the officer, apart. The result was an acquittal of a person who was otherwise caught red handed. By the time the lawyer got done tearing the report apart, the officer looked like a clown. Why that report wasn’t reviewed by a supervisor and corrected, I never found out.
I would not want to be the paramedic or his employer if the report I audited was ever called into question by a regulatory agency, court, or even a physician.
Quite bluntly, my eight year old grandson could write a better report.
The moral of the story, if there is one, is this. What your write in your report is a reflection of your abilities as an EMS provider. I am not the best speller in the world, but I use one tool that very few people in EMS seem to use. That is spell check. Even if the PCR system has a poor spell check, and many of them do, most providers I know have a smart phone. Which is a great tool for checking the spelling of not only medical terms, but common words as well.
The struggle to have EMS recognized as a medical profession started before I was in EMS, continued throughout my career, and is still going on as I type this.
Illiterate reports like this don’t help at all.
This all sounds very preachy, I know. Still, writing a decent report is not that hard. It’s not even EMS specific. Writing is something that is taught from Kindergarten on and an adult who is out in the working world should not be writing a document like this.
With that, I’ll step off my soapbox and await your comments.