Motivation for Documentation

In service to the communities you treat, for whom you work, or where you reside, you have been well-schooled on the scores of legal motivations for writing a report after every emergency medical service-related call. Primary motivators start with the protective need for clinical and legal information about the patient (their complaint, your physical assessment, treatment and patient response to treatment, and the summary information regarding the patient’s final disposition). The protective value of strategic documentation and its information serves to ward off potential litigation against you and your partners, your management and the agency you represent. There has been much information published about the value of a legally defensible report; however, regrettably for some prehospital providers, the threat of legal action is still not perceived as a tangible risk or a catalyst toward self-improvement in data collection and report writing. There are those providers who simply cannot be coerced into implementing corrective documentation measures. Read on for alternative rationales for improving your documentation.

Administrative Motivators

As a practicing provider, you have also been well-schooled in the administrative motivators to record and store accurate information about the patient encounter. This relates not just to statistical valuation for staffing patterns and strategic placement of service units, financial performance and reimbursement, and occupational exposure issues, but also to capital expenditures sustained by fundraising ventures and government subsidies. All of these motivators allude to accountability to yourself, your jurisdiction or agency, and to your patient. Are these administrative motivators, coupled with legal motivators, enough to drive your documentation into a quality, information-rich runsheet?

No matter what motivator drives your documentation, the information you provide has to be accessible and functional to those who use it here and now or those who may use it later. The data or informational statistics must be reliable, consistent and standardized through terminology or abbreviation; it must be timely and readily accessible. Accessibility to the prehospital information can be as simple as emergency room personnel reading a runsheet to collect emergent information about the patient or as complex as insurance data entry personnel collating information from data entry prints on a continuum of data collection from your patient encounter through hospitalization and discharge.

Improving the System

Look closely at the following words —even recite them aloud: Every call or patient encounter provides the necessary data for quality improvement in your emergency medical service system. What constitutes system improvements? Financial performance through higher reimbursement from appropriately detailed billing (information from the runsheet); improved operational performance through increased staffing/positions, capital equipment, and strategic location of ALS or BLS services. Data collected from every call allow trending of service performance, through skills performed relative to patient outcome, promoting training and support for basic and advanced level skills. Your documentation and your data support system-wide improvements.

How does every call or patient encounter expand into system-wide improvements? The data or finite information generated on every runsheet provide information about performance measures and whether or not they were met, or if changes (improvements) are needed. As an oversimplified example: Data taken from the patient report reveal that the patient with chest pain received supplemental oxygen via nonrebreather mask at the dosage of 10 liters/minute. The service performance (standard of care), as dictated by the protocol and performed by the BLS or ALS provider, was met through your documentation of the medication (oxygen), dosage (10 liters/minute) and mode of delivery (nonrebreather mask). Finally, the runsheet data provide justification for skilled personnel to deliver the level of care commensurate with the patient encounter. It also supports justification for funding of provider education and continuing education, or even elevation to the need for advanced skills. This is a simplified illustration of how the data collected from your runsheet work toward system-wide improvements, enhancing your performance and personal satisfaction.

On a broader spectrum, data derived from your patient care runsheet can prove an increasing call load, and may justify expenditures for additional apparatus and staffing positions. In the alternative to capital expenditures, the data can prove a need to divert some of the call load taxing busier agencies. As another simplified example, if you are an ALS service running a disproportionate number of BLS-level calls, you may be able to justify a BLS unit at your location, reserving the ALS unit for true ALS emergencies.

You are empowered to improve the quality of service to your patients and reap rewards for yourself through system-wide quality improvements. Your reward is driven by runsheet data that can only come from you, the on-the-street provider. These quality changes are sparked by a catalyst—the data you provide. Every patient encounter providing quality data equates to the potential for quality improvement. Your incentive for providing a detailed runsheet with every run should be the system-wide reward that benefits you directly.

Data Collection

The on-the-street information you collect, how it is managed and how it is used are the foundation of quality improvement models and provides the catalyst for improvement. Your information must be collected constantly and consistently with every patient encounter, and it must be reliable, using terminology and abbreviations consistent with prehospital medicine. Computerized systems are not a necessity. They do, however, simplify data collection and provide a more standardized data collection parameter. They also provide for easily accessible data, quick analysis of the information, and can readily track trends. Handwritten or computerized data collection must provide useable information. The old cliché “garbage in …garbage out” applies here.

Quality assurance models provide a retrospective view of the outcome of the emergency medical services provided, with the intention of identifying problems from the data collected. From here, quality planning can be initiated to meet the needs of patient care and provider issues. The current trend in data collection is toward the evolutionary process of quality improvement based on quality control through continuous data collection, monitoring of performance (for compliance with the standard of care/protocol), and analysis of the information for the purpose of improving services provided and improving patient outcome and consumer satisfaction. The data you generate with each run are critical for consistent up-to-date data collection, ongoing management and analysis of the information, review of performance parameters and the process of transforming the data into useful information to effect change. This information results in improvements in the EMS system as a whole. Of course, the outcome information sometimes shows a need for quality control or control of the quality of care provided through the reassessment of performance levels and corrective action plans, ultimately yielding improvement of the system.

Summary

The quality improvement plan relies on controlling quality of care through improving the process or system as a whole. Your ongoing data collection is paramount to the process of system-wide improvement and performance, enhancement of financial performance, operational performance and overall service performance and satisfaction. The threat of litigation and having to defend yourself from a claim of wrongdoing still looms every time your wheels turn. Your runsheet must serve and protect you. Look at the NFPA 1710 standard, which was enacted to serve and protect firefighters. This standard was enacted with their personal safety and well-being as the principle behind staffing requirements. At what stage of draft do you suppose the NFPA 1710 standard would be today if the relative data were collected sporadically or were not tracked for each service-related death? It may have taken many more service-related deaths to effect change for a system-wide improvement in operational performance. Every call merits documentation and data collection. Your data are catalysts for change.