Troubles With Bubbles

      Ask anyone in EMS for their short list of what duties they like the least, and completing paperwork/documentation will routinely make the top five. But, like it or not, patient care reports (PCRs) serve multiple purposes, all of which are essential in the day-to-day operations of any quality prehospital care system.

   First and foremost, your PCR is a medical record of the assessment and care of a patient in the field setting. Chief complaint, initial assessment and history of the present illness/current condition form the backbone of the patient's medical record from the field setting. Vital signs, lung sounds and information obtained from your diagnostics, e.g., blood sugar level, EKG, pulse oximetry and capnography values, all provide baselines for the hospital staff to build upon as they assume care of the patient.

   Second, there is the matter of reimbursement and keeping an EMS provider agency financially solvent. In the world of continually shrinking medical reimbursements, poorly completed or inaccurate PCRs produce multiple problems. Loss of revenue from reimbursement is clearly first and foremost. There is also time wasted to recomplete and resubmit paperwork while simultaneously increasing business office costs.

   Last, and by no means least, is producing an accurate medical record for legal purposes. Frequently, years pass before legal action is initiated, and the likelihood of retrieving the details of your performance from any given call diminishes with every passing day. In the end, a Xeroxed copy of the PCR you filled out 5½ years ago is all that remains to bring you mentally up to speed on a call you must soon testify about.

   Each of these three elements of prehospital care is incredibly important to our profession. Initially, PCRs were simple designs. The details of patient assessment, care provided (both on scene and en route) and disposition of the patient when turned over to ED staff were covered in narrative format. A few boxes to check off vital signs and EKGs, along with patient billing information, wrapped up the package.

   With the passing of time, information needs relative to all three elements mentioned previously continued to increase. To gather all that information, the evil "bubble sheet" design emerged. Make a choice, fill in the bubble, move along. Information needs continued to increase. More bubbles were added. To capture more data, space for narratives was decreased or, in some cases, removed entirely. While this may have provided additional data, the trade-off with the limited or nonexistent narrative was loss of ability to document the "sequence," i.e., how events unfolded during the time the patient was in your care.

   The sequence of events during a call is frequently one of the most important parts of a legal case. In one lawsuit I was helping defend, the entire case hung on "when the EMS team recognized the patient was hypoxic and administered high-concentration oxygen therapy." Though the narrative section was small, the information was adequate to successfully defend the case. With only a basic bubble sheet PCR, we could not have identified that sequencing.

   Another problem with bubble sheets is the sheer number of bubbles to be filled in. One agency I know uses a legal-size PCR and, except for five lines set aside for narrative, the front and back, minus a small area for patient billing information, are entirely bubbles. Hundreds of bubbles, and the provider needs to hit the right one every time. Just having all those bubbles in your field of vision increases the likelihood of error, and with each error comes three possibilities: reduced or no reimbursement; errant patient history is entered and passed along to become part of the permanent medical record; or, the error could be what sinks an EMS team in a lawsuit, i.e., "patient vomited and aspirated, ultimately succumbing to ARDS. Crew claims they suctioned the patient. Suction not marked." Suddenly the old adage, "didn't write it, didn't do it" makes more sense. In this case, it's missed the bubble, now you're in trouble.

   The increasing sophistication of tablet and PC-based PCRs and their ever-improving software makes them the logical industry-wide choice, as I see it. Drop-down windows, much improved medical spell-checks, the ability to wirelessly transmit the document and more intuitive design all tip the scale in favor of technology. Other than a theoretical savings in expense when compared with tablet or PC-based systems, the bubble form brings nothing else to the table. I say "theoretical" because, while bubble forms are cheaper to use on a daily basis, do lost reimbursements due to error or lost lawsuits offset the true cost in the long haul?

   Every time I am asked to help defend an EMS lawsuit and I see that the providers have bubble sheets as PCRs with a couple of lines for narrative, I cringe. When I see the PCRs that have no space for narrative whatsoever, it makes me want to cry. Now you know why. I vote to move the bubble form to the National EMS Museum in Washington, DC. Sooner would be better than later.

   Until next month...

   Mike Smith, BS, MICP, is program chair for the Emergency Medical Services program at Tacoma Community College in Tacoma, WA, and a member of EMS Magazine's editorial advisory board.