When the idea of lifesaving interventions comes to mind, most people outside of the medical field think of the physical and real-time work that goes into emergency care, such as ambulance dispatch and paramedical response. But the administrative work that’s done behind the scenes is just as important to saving someone’s life and ensuring that they get the quality of care that they deserve. Foremost among these is the task of writing patient care reports, or PCRs.
PCRs are meant to document the whole continuum of patient treatment, from when they’re first attended to by emergency services to when they’re released from the healthcare facility and on the road to recovery. Readable, well-written, and organized PCRs make it easier for medical caregivers to implement appropriate medical action for each patient involved. The converse applies as well—if a PCR is hard to decipher and doesn’t convey the full picture of the patient’s situation at one glance, it may delay the application of necessary medical care and make it even harder for the patient to recover.
Knowing that, what can you and your emergency medical services (EMS) team do to write better PCRs? Here are a few tips that, when applied, can greatly improve your patient care quality.
Onboard New ePCR Software to Write Your EMS Reports
The first thing you should consider doing is to shift from an analog pen-and-paper or typewritten record-keeping system, such as EMS ePCR software. This solution will allow you to generate consistent, up-to-date patient reports from a centralized repository for your EMS data. It’s even better if the ePCR software is integrated with other modules such as CAD, scheduling and billing, which will make it easy for your facility or department to summon a full view of any patient’s profile in seconds, including their computer-aided dispatch (CAD) records, billing records, patient reporting, and upcoming schedules. Moreover, the new system will enable faster and tighter communication between your emergency medical technicians (EMTs) and paramedics and the personnel in a medical facility, like doctors and nurses.
With an ePCR solution, you and your staff can save time on data entry, processing, and retrieval for huge volumes of patient data, which will be of great relief when things get especially hectic. You can easily build your own PCR templates and customize the data fields to be filled in, facilitating quick submission and immediate syncing to the cloud. The digital system will also eliminate some of the errors associated with paper forms, such as illegible penmanship on the part of the documenter or overly brief patient narratives due to limited physical space on the form.
This major upgrade to your PCR record-keeping system will increase the accuracy and reliability of your reports. In turn, you and your staff can stay on top of your patients’ situation and deliver timely, responsive care without second-guessing the correctness of your patient data.
Train Staff to Write PCRs in a Detailed and Consistent Manner
It may be high time to utilize better automation and calculation capabilities through a new ePCR software solution, but you shouldn’t think of this as a substitute to the human element of the work. On the contrary, it should supplement documenters’ ability to write complete reports and help them focus on describing the patients’ narrative situation in fuller detail. After all, writing the narrative part of a PCR is something that only a human can do.
Empower your EMS staff to properly accomplish the human element of their documentation work by training them and allowing them to hone their report writing skills further. It should eventually become like second nature to them to prioritize the right data in their report writing, and to use any of the following formats for structuring patient information:
- SOAP (subjective data, objective data, assessment data, and plan)
- SOAPIER (subjective data, objective data, assessment data, plan, intervention, evaluation, and revision)
- CHARTE (chief complaint, history, assessment, Rx [medical prescription], transportation and treatment, and events)
- IMRaD (introduction, methods, results, and discussion)
Don’t forget to remind your documenters to be as specific as possible about the circumstances of each case. Encourage your staff to describe each intervention and each procedure with utmost clarity, as this will help other members of the medical team decide quickly on the next steps.
Operationalize PCR Protocols for Special Situations
There may also be instances in which writing a PCR will be a more complex task. You must also be able to create a system of report writing for special circumstances, like the following:
- Cases in which the patient cannot communicate clearly in English because it’s not their first language. The documenter may need to contact the hospital to tap the services of an interpreter in order to get clear information about the patient’s symptoms, medications, and the like.
- Cases in which the patient is visually impaired or hard of hearing. The PCR must reflect these details, and the first responders must take special care to accommodate the patient’s impairment, disability, or handicap.
- Cases in which the patient is geriatric. Documenters must not assume that these patients are confused or senile when they’re taking down the latter’s details on their PCR.
- Cases in which patients refuse treatment. In these cases, documenters should make sure that they can obtain a patient refusal form, signed in front of a credible witness like a family member or law enforcer.
These cases demonstrate that some PCRs may take extra time and attention to compile, and that their completion requires awareness of certain nuances. Train your staff to respond to these situations with confidence and composure, and make sure that it reflects in their documentation.
Make Your PCRs Easy to Process for Reporting and Other Purposes
Lastly, remember that the data kept in your PCRs can be used in the future, and by people outside of your EMS department. PCRs compiled over a prolonged period may reveal trends that are important to your medical practice, such as patterns in the accident-related cases you accept. If you can regularly collect and analyze data on these trends, you can further enhance your response to these situations the next time they occur.
In addition, your PCRs can serve as support documents for others in your care provider network, such as insurance companies and rehabilitation centers. They can also be used by other professionals, like lawyers who may need PCRs to settle cases in court.
You will be able to strengthen the efforts of other partners involved in your patients’ health and wellbeing by compiling well-written and well-organized PCRs. Upskill your staff to write excellent PCRs using a vocabulary that’s easy to digest and using a structure that can immediately highlight the report’s most important narrative details.
In the end, you and your staff should be able to maintain an ePCR software system that demonstrates your adherence to the proper standards of patient care, as well as full transparency about the medical interventions that were undertaken. Clarity, detail, organization, and consistency are the keys to every good PCR. Use the tips detailed above to operationalize effective PCR writing and record-keeping, and supplement your department’s on-the-ground efforts to save human lives.