Tell Me A Story

     Documentation is an important but often overlooked part of every EMS call. How much time does an EMS provider put into documentation? How much time should an EMS provider put into documentation? How detailed should the reporting be? Would your reports hold up in court? The answers, and some additional points as well, are important for every call you respond to.

The Basics
     Every EMS agency utilizes some method of patient care reporting. Some use standard forms created and distributed by governmental regulatory bodies (state EMS agencies), and some use forms they, themselves create to include specific information and data points. Agencies all over the country are now moving to electronic reporting.

     Regardless of the method of reporting, the majority of reports can be broken down into several categories, with possible variations within those categories. Each EMS provider should be intimately familiar with the reporting method his agency utilizes; the form and format of patient care reports will vary from state to state, and possibly even from locality to locality and agency to agency. Typically, these forms include spaces in which to write information, as well as dots to fill in. Remember that in most cases, the report is a legal document and an important part of patient care.

     For paper forms, it is usually advised that the provider completing the report use a ballpoint pen and apply firm pressure, as most reports have multiple copies. Handwriting should be clear and legible, and words should be spelled correctly. It is usually acceptable to use abbreviations, but which abbreviations, and for what conditions, should be clearly understood. Additionally, all blanks should be filled in, to avoid giving the impression that the report is incomplete-or, more important, allowing an opportunity for the report to be altered.

     When writing a report, it is important to tell the story of what occurred on scene. Be as specific as possible, and try to include things you see, hear, touch and smell. Many times the use of pertinent negatives-meaning ruling out things that may be typical of patients with similar illnesses-is important as well. These negatives could have a big impact on your treatment.

     Most reports will begin with general information: a report number, usually a report identifier for reference purposes, and the date (usually in MM/DD/YY or MM/DD/YYYY) format. Always remember to use leading zeroes to avoid blank spaces. For instance, to avoid the possibility of tampering, February should be documented as 02 instead of 2. There also will be places to provide agency information, either via a predetermined code assigned to the agency or by simply listing the agency in an appropriate space. There may be space for the specific responding unit (Medic 4, Ambulance 2) as well. A form will have spaces for the incident nature and location; it may even include latitude and longitude (for agencies that utilize GPS) or zip code. There may also be places to indicate the type of location where the emergency occurs (e.g., roadway, residence, healthcare facility), other responders on scene (fire, law enforcement, other EMS, facility staff) and call times. Call times may include the times of call reception, dispatch, response, travel, arrival on scene, arrival at the patient's side and in service.

     Next, most reports include some place to record information like the patient's name, address, spouse and/or guardian (if applicable). Phone number, date of birth, age, gender, weight and even race may also appear. A recent trend includes patients' social security numbers; this is to tie the prehospital report information to information gathered in the hospital. Additionally, the SSN is one of the main identifiers for NEMSIS (National EMS Information System) project data. Every effort should be made to obtain this information, even if it is just the last four digits.

     Following the patient information, there is space to list information about the patient's medical history. Typically, there will be check boxes for commonly encountered pre-existing conditions (asthma, diabetes, COPD, cardiac, hypertension and seizures, to name a few). Be thorough in your patient and bystander interviews to include all past illnesses, even those that aren't related to the current emergency. The patient's current medications should also be noted, with dosage and frequency. Also include any over-the-counter medications the patient takes regularly (such as daily aspirin). Ask about and record any allergies and untoward reactions to those medications if there is room in the report.

     Next is the "meat and potatoes" of every report: information about why EMS was called. The chief complaint is what the patient tells you is wrong with them. It's acceptable to use the patient's own words: "My stomach hurts," or "I'm having trouble breathing." It may also categorize several typically encountered complaints for the provider to include their own impressions of patients' injuries or illnesses. Often, there will be a subjective assessment narrative area where information gathered on scene can be documented.

     As you perform the patient assessment and take vital signs, these findings will have to be documented as well. Note the time and, if possible, who's gathering this information. Document pulse, with rate and quality; respirations, with rate and quality; and blood pressure, as well as level of consciousness (typically via the AVPU scale), pupil response, EKG interpretation, skin color and temperature. Glasgow Coma Scale score and categorization of extent of illness (CUPS status) will also be listed.

     When documenting your assessment, try to keep your reporting style consistent. Many EMT training programs will also teach mnemonics to help you document information. Be sure the mnemonics you utilize are acceptable to your agency or system.

     As you document the interventions you perform, be specific. For instance, if you are administering oxygen, document the method of delivery (nasal cannula, non-rebreather, bag-valve mask), as well as the rate and any changes in patient condition. For medication administration, include the dose and route. Also document any application of equipment (backboarding, etc.). Though you are the one writing the report, all treatment interventions and procedures done by personnel from your agency for the same patient should be documented on the same report.

     Finally, include all pertinent information regarding the patient's disposition. If you are on scene as a provider for a first-response agency, document the name of the provider and agency to whom you are turning over care. If you are with a transporting agency, include the patient destination, to what part of that facility the patient was delivered (emergency department, labor/delivery, etc.), the room number and the name and credentials (nurse, doctor, etc.) of the person to whom you turned over care. Be sure to mention that a full report was given to that person. That person may be required to sign your report to verify the transfer of care.

The Importance of Good Documentation
     The EMS patient care report is significant not only in the prehospital setting, but at the hospital as well. Those who continue your patient's care are going to want to know what happened prior to that patient being placed in their hands. Giving them as much information as possible will assist their diagnosis and treatment. Hospital staff may not give aspirin to a patient if they know from the EMS report that aspirin was already administered. The more critical a patient is, the more will need to be gleaned from the EMS report.

     Also, most EMS patient care reports are used for quality assurance reviews. It is not uncommon for random reports to be regularly culled and examined, or for reports to be reviewed for data for QA studies. Fully completing each report as clearly as possible will help QA efforts.

     Today, many organizations bill for service. The patient care report is often used to determine what was performed and the mileage involved.

     Finally, many EMS patient care reports are considered to be legal documents that can be entered into legal proceedings. At times, you may be asked to discuss a report that was completed months or even years ago. Clear reporting will assist your recollection of events and help you discuss, and possibly defend, your actions.

The Future of EMS Documentation
     The technology age is making its way into EMS agencies and receiving facilities with applications providers can use to document patient care information and submit it to a data repository. These applications range from the scanning of paper forms to PC-based reporting from stations or hospitals to mobile applications that use laptop computers or personal data assistants to store information. All of these applications record the same information as traditional paper patient care reports. The electronic reporting systems greatly ease the work of data collection, as information can be gleaned from each report almost instantly. This data can often be merged into hospital databases, which facilitates the transfer of care.

     While the ease electronic data collection brings to the QA process has led to many improvements for agencies and systems, one problem has been the standardization of data elements, collection and analysis. Many state entities have their own methods of data collection, which has led to inconsistencies among states and difficulty in data sharing. One of the biggest efforts to remedy this is the NEMSIS project, which has been initiated to develop a national EMS data set, based on standard data points, that can be utilized by every EMS agency in the United States. In the future, every report that's generated will become part of the NEMSIS database. For more, see www.nemsis.org.

     The author gratefully acknowledges the assistance of Jodi Kuhn from the Virginia Office of Emergency Medical Services.

Timothy J. Perkins, BS, EMT-P, is the EMS systems planner for the Virginia Department of Health's Office of EMS. He has over 17 years of EMS operations and management experience. E-mail him at tjperkins5@yahoo.com.

Tim Perkins is a featured speaker at EMS EXPO, October 11-13, in Orlando, FL. For more information, visit www.emsexpo2007.com.