Documentation: Do These Five Things Now

Thorough and accurate documentation is an age-old challenge in EMS. But according to Steve Wirth, Esq., EMT-P, founding partner of Page Wolfberg & Wirth LLC., improving documentation should be seen as evolutionary, not revolutionary. It should improve over time.

Wirth presented “Five Fast Fixes to Improve Your EMS Agency’s Documentation” Friday March 6 at EMS Today in Tampa. Here are his recommendations:

1. Give positive feedback. Positive feedback works better than negative when discussing less-than-stellar documentation among your employees, said Wirth. Instead of reprimanding an employee who doesn’t get patient signatures 21% of the time and threatening termination, note his or her improvements in getting to 79% and encourage further improvement. Be specific in your encouragement—i.e., “The following staff members have exceeded 90% signature compliance for the month. Fantastic job!” Constant criticism fatigues employees. Use the “sandwich method” for delivering criticism. Praise in public, criticize in private, Wirth advised. Consider incentives and rewards such as a day off or a “wall of recognition” honor for documentation milestones. One caution: Don’t link incentives to billing in any manner.
2. Start clinical documentation improvement (CDI). Specific, objective and measurable criteria similar to a treatment protocol can help ensure accurate charting and objectively measure improvements. Once you define specific documentation expectations, you can provide specific documentation feedback to staff. Example: a paramedic documented cardiac history 91% of the time on a chest pain assessment call in the third quarter of the year, but just 23% on another assessment finding. Use these numbers to create an improvement program. Track DCI compliance statistics for documentating key performance indicators (KPIs) over time. CDI checklists can be a useful and objective tool to facilitate the next strategy in the list: peer review.
3. Start documentation ‘peer review’. This one is easy, said Wirth. It can be as simple as two partners checking each other’s work at the end of a call or shift. This should be built into your system’s culture, Wirth said. The mere act of observation changes the phenomenon being observed. “When people are watching you, you tend to behave,” he said. A fresh set of eyes can change the perspective and catch mistakes or omissions; two sets of eyes are better than one. Peer review builds investment in writing better PCRs, improves collaboration between staff, fosters learning from one another, and builds confidence in constructive feedback.
4. Reinforce underlying skills. Often, substandard clinical documentation may be caused by poor underlying clinical or communication skills among EMS practitioners, Wirth stated. Math skills, spelling and grammar, technological proficiency, anatomy and clinical terminology knowledge, and patient assessment skills are all critical to good clinical documentation. Poor grammar and a misplaced decimal period can hurt patients, Wirth said. There is no shame in offering remedial education on spelling, grammar, composition, basic math and other fundamentals. Partner with a local school or tutor to offer a seminar or in-service education for crew members. Also, some documentation problems may be caused by the technology and software itself, so make sure all crew members are trained on the capabilities of your PCR system.
5.  Use a team approach. Make your documentation improvement process multidisciplinary and continuing, Wirth advised. Work with other agency departments on documentation improvement initiatives. Every EMS provider should spend a day in the billing office, and vice versa, to gain an appreciation of what others do, and how each can make the other's life easier. Documentation isn’t “owned” entirely by the clinical and operational side of the agency; better documentation benefits the whole service, Wirth said. Open a dialogue and encourage everyone to bring ideas, suggestions and concerns to the table. Leaders must be open-minded to new approaches.

As with clinical skills, when it comes to documentation, treat every patient as if it was their very first call—and yours, Wirth said. A few simple strategies implemented now can start your agency on the path toward rock-solid documentation.

Jonathan Bassett is editorial director at EMS World. Reach him at jon@emsworld.com