Webinar: Creating Complete Clinical Records

Posted on October 25, 2018


Why Does It Matter?

The Joint Commission requires hospitals to keep the “record of care, treatment and services”, which includes the complete clinical record. And of course, the complete clinical record not only includes treatments provided in the hospital but those outside of the four walls. The pre-hospital data originated with EMS/Fire-based treatment meets the record of care standard and is also exceptionally beneficial within the hospital setting for treating patients effectively.

When data is available in the hospital, physicians use that data to make care decisions and evaluate patient need. In fact, a majority of emergency physicians believe the EMS patient care report is “important or “very important” and prefer an ePCR to a handwritten note.                                     

Data Exchanges Meet Requirements and Provide Critical Information

Only 14% of hospitals use any form of automated data exchange yet having this information is critical. Data exchanges (such as ESO HDE) allow staff to

  • reference records and avoid transcription errors – ensuring the correct information is relayed in time sensitive situations.
  • Save time on searching for records – no waiting for faxes to come through or searching for manual paper records
  • Access EMS records to support quality reviews – both internally and for the Joint Commission, having the EMS record in-hand can assist in achieving compliance

Watch “How to Create Complete Clinical Records” to learn best practices for creating a complete clinical record, supporting Joint Commission compliance and serving your hospital’s most vulnerable patients. Speakers Dr. Brent Myers and Nicole Hayes cover

  • The full scope for the record of care (RC) standard
  • Empowering EMS to help your hospital be Joint Commission complaint
  • Benefits for patients and clinical staff
  • Tips for reducing manual errors in records