‘DOCUMENT’ to Improve Run Reports for Your EMS Agency
Accurate documentation for EMS agencies is key to success both in the field, and in the office. Not only does it improve patient outcomes, it also provides accurate claims processing, furthers quality assurance, and defends against malpractice.
At ESO’s WAVE 2019 conference, EMS Division Chief Douglas Randell of Plainfield Fire Territory in Plainfield, IN, presented a session aimed at improving documentation quality in an EMS organization, and went on to share his own innovative and acronym-ed standard for documentation that is meeting great success in his organization.
“Complete and accurate documentation is the standard in our organization and is expected of all providers,” explained Randell. “But how do you create a process that really delivers this high-quality documentation?” Randell outlined the numerous questions that help gather pertinent information from a call, including:
- What happened to the patient?
- What did he or she tell you?
- What did you observe on the scene?
- What is your field diagnosis of the patient?
- What treatment and transport decisions did you carry out?
Most providers employ one of the two most common protocols: SOAP (Subjective, Objective, Assessment, Plan with sometimes the addition of Intervention, Evaluations, and Revision) and CHART (Chief Complaint, History, Assessment, Rx, and Transport). Randell, however, proposed agencies consider using a more in-depth and comprehensive protocol to truly paint a full picture of what went on during a call.
A New Protocol, A New Acronym
He has given this new protocol the acronym “DOCUMENT,” and his additional steps – some named with a bit of humor making them hard to forget – are delivering excellent results at Plainfield and beyond.
- D: Demographics, Dispatch, Distance
Be sure to record: Name, address, phone, social security, date of birth, medical insurance, next of kin (if minor), signatures, response time, location type, dispatch completing, added miles
- O: On-Scene Assessment
What is your general impression? Describe what you see when you arrived on the scene. What is the patient doing? What position is the patient in? Put the reader of your report in your scene. Be descriptive!
- C: Chief ComplaintWhy did this person call 9-11? Be descriptive; use quotations when appropriate. The narrative adds to the validity of the run.
- U: “U say what… happened?”
So what happened? What did the patient tell you? Remember to include SAMPLE (Signs and Symptoms, Allergies, Medications, Past medical history, Last oral intake, and Events leading up to present injury) and OPQRST (Onset, Provocation, Quality of the pain, Region and Radiation, Severity, and Timeline).
- M: “My Eyes! My Eyes!”
What did you observe with this patient? What’s his or her behavior? What do you see to trigger your level of suspicion? Document all of the behavior, not just the extreme. Look around the scene and play detective a bit; is there anything out of order?
- E: Examination
What are the physical exam findings? What are the pertinent vital signs? Describe the finding of the physical exam: head, neck, chest, abdomen, pelvis, back, lower extreme, etc.
- N: “’N the verdict is…”
What is your “field diagnosis? Use “Impression,” use “Differential,” and use “medical decision making.” Sit with your medical director and discuss if this ok for your team to do and how to go about it.
- T: Treatment and Transport Decisions
What were the treatments? What was the outcome of each treatment? How was the patient moved from the scene to ambulance? How was the patient positioned and transported in the ambulance, and moved from the ambulance into the ED? Was there any change in their condition en rout to hospital? Document all of this.
Scoring and Checking for Improvements
After introducing the new protocol to his team, Randell created a rubric with which he “scored” run reports from each shift. He began by reviewing one PCR per person, per shift. He shared the scoring criteria with his team, offered training and a “soft” implementation, then a hard implementation three months later.
As time progressed, he began to see improvements in the run reports, and grouped his “high achievers” (scoring 95% or better on the rubric) into a group for which he checked only every other shift. He added additional training opportunities, gave constant feedback, and even shared success rates between shifts to build friendly competition. He soon saw his number of high achievers grow, and as the built more trust, they needed fewer check-ins from Randell.
Currently, Randell is continuing to refine the DOCUMENT protocol, looking for ways to automate some of the steps within the process. He notes that, surprisingly, his team members did not see a substantial increase in time required for completing their run reports; instead they simply benefitted from the additional direction and knowing what was expected to be included. The workload for the supervisor reviewing the reports did increase, of course – Randell stressed that even automating steps would still require you to read the narratives – but over time, as the number of high achievers increased, it meant reviewing fewer and fewer reports.
Randell continues to spread the word about this new protocol to other agencies around the nation, encouraging teams to complete more accurate reports and for officers to become more engaged in the training and accountability aspect of documentation.
“By changing the mindset, we changed the game,” he explains. “This is a possibility for us all. Increase your training on your standards and processes. Create a rubric and methods on how to create what you envision as the ‘perfect’ run report. Collaborate with your administration and medical director. This is a platform that can work.”