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What to Include on a Patient Care Report (ePCR)

ESO Staff

Accurate patient data is arguably the most valuable tool a medic has at his or her disposal. It not only informs immediate treatment decisions, but it shows what is – and isn’t – working. It plays a pivotal role in efficient patient hand-off at the ED, and it dictates the type of care he or she will receive in the minutes and hours after.

The value of accurate patient data extends to life back at the station as well; it can make or break billing and reimbursement processes, maintain compliance in reporting requirements, and even help secure grants, create effective CRR programs, and conduct Quality Assurance/Quality Improvement projects.

While the value of high-quality clinical data can not be overstated, why do so many EMS agencies struggle with obtaining, storing, and analyzing data? The answer is the “data deluge” and the lack of proper tools to handle it.

Whether an agency is still using outdated pen-and-paper methods to record patient data, or is struggling with a software tool that doesn’t coordinate with other agency tools, many agencies have  likely experienced the headache that comes with too much information. Issues like duplicated data entries, incomplete patient care forms, painful workarounds, missing paper records, and clunky spreadsheets make data difficult to access.

ePCRs: Patient Care Reports for the 21stCentury

Over the last 30 years, EMS agencies and hospitals alike have recognized the value of going digital with patient records, coining the term “electronic patient care reports” (ePCRs). A digital record that can follow a patient throughout the spectrum of care – including through discharge and billing – not only improves the efficiency of paperwork, but also directly improves the quality of care.

With all pertinent information, medications, lab results, and notes from other providers in a single, easy-to-access digital document, providers can make better informed treatment decisions and spend less time tracking down missing information or reentering data.

For pre hospital care specifically, ePCRs deliver a wide range of benefits, including making it easier to create complete clinical documentation in the field, access to patient history, and compile post-call analytics back at the station.

About Patient Care Reports

Digital patient care reports are slowly but surely changing the way patient information is recorded on a call, but they do not change interactions with patients. Instead of jotting down notes on a paper form, medics quickly and easily record the same information using a tablet and a digital form. Recording this data directly in a digital format saves time, makes the data more secure and reliable, and prepares it for other uses like handoff to the ED and analysis in overall agency operations.

What Patient Care Reports Should Include

Just like the paper version of patient care reports, ePCRs are meant to be complete and contain all pertinent information to help deliver proper patient treatment and track performance metrics. EMS agencies have numerous benchmarks set for their own operations, as well as those suggested by professional organizations, insurance providers, and even some government agencies. The ability to quickly record required data points for later automatic analysis can save countless hours for agency staff and administrators.

Some software tools allow agencies to create customized forms within their ePCRs to ensure all required data is collected in the field using standard formatting and terminology. Important potential data points to collect include:

  • Presenting medical condition and narrative
  • Past medical history
  • Current medications
  • Clinical signs and mechanism of injury
  • Presumptive diagnosis and treatments administered
  • Patient demographics
  • Dates and time stamps
  • Signatures of EMS personnel and patient
  • Amount of miles in transport (for reimbursement purposes)

Obstacles to Efficiently Creating Electronic Patient Care Reports

As the adoption of ePCRs has ramped up in the last three decades, technology has evolved along with it. However, technology includes its own set of challenges. Onboarding an entire EMS agency to a new records system takes a coordinated effort and can require a substantial investment in time and money. As a result, some agencies find themselves working with outdated ePCR systems.

Another challenge is ensuring the ePCR tools work well with the agency’s other tools and operating systems. While some setups require tedious workarounds, others require users to enter duplicate information in multiple places. Some ePCR solutions lack the useful analytics and reporting features that make agency data genuinely actionable, leaving rich data sitting in a system with little ability to process and share it.

While digital records are still an improvement over pen-and-paper methods, some EMS agencies miss out on the substantial workload efficiencies and automated analytics that modern ePCR tools can bring to the table. Agencies thinking about purchasing or transitioning to a new ePCR vendor should take their time and ask the right questions to ensure they are making the best decision for their needs and goals.

Comparing Documentation Methods: SOAP vs. CHART vs. IMRaD

Accurate, complete, and rich documentation in patient care reports can improve patient outcomes, provide accurate claims processing, further quality assurance, and even defend against malpractice. Offering guidance on what elements to include in narratives can result in more complete run reports.

The CHART and SOAP methods of documentation are examples of how to structure narratives. Some medical professionals use IMRaD format similar to what’s used in medical journals as a framework.

SOAP:

  • Subjective observations: personal views of feelings, chief complaint, history of patient illness for chief complaint (including onset, location, duration, severity, etc.), general history (including medial, surgical, family, social), review of symptoms, and current medications and allergies.
  • Objective observations: vitals, physical exam, labs, imaging results, diagnostic data
  • Assessment: problem/diagnosis, potential differential diagnoses, discussion
  • Plan: primary treatment administered, next steps, patient education, communication with ED

CHART:

  • Complaint: chief complaint (including onset, location, duration, severity, etc.), other symptoms
  • History: history of chief complaint and personal history
  • Assessment: observations, primary impression, presumptive diagnosis
  • Rx (Treatment): medications and fluids administered
  • Transport: Information about where and how patient was transported, condition during transport, communication with receiving facility, and details of handoff at ED

IMRaD: More common in medical journals and papers, the structure can also be a helpful format for organizing a narrative in a way that is easy to write and for others to review.

  • Introduction: background, overview, setting
  • Methods: primary impression and treatment administered
  • Results: any results of treatment, change in condition
  • Discussion: any additional observations or helpful information

At a past ESO Wave 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, sharing his own innovative acronym that is meeting great success in his organization. Read more about Randell’s expanded “DOCUMENT” process, and how agencies could consider using a more in-depth and comprehensive protocol to paint a full picture of what happened during a call.

New ePCRs Improve Patient Care While Improving Analytics and Reporting

Today’s top ePCR software tools offer direct improvement to patient care by streamlining communication and reducing the chance for human error. For example, customized forms in the system can be progressive, meaning a medic cannot move on to the next field without recording data for all required fields first. This results in more complete records and less time making follow-up calls to track down missing data.

Drop-down menus offer standard choices, further reducing the chance for mix-ups. Connected databases (such as integration with Handtevy) can help ensure treatment en routeto the ED is accurate, while patient look-up features can instantly offer a patient’s known history. Recording complaint and symptom information in an interactive, digital format makes it easy to quickly and accurately record all required information for better assessment and treatment.

Once the patient is transferred to the ED, the value of an ePCR continues. Medics no longer need to return to the station to transcribe their handwritten notes into the agency database. The ePCR can be ported over for easy inclusion in agency analytics and reporting, which is helpful for meeting professional and national reporting requirements, conducting QA checks, applying for grants, and telling the agency’s “data story.”

See the Next-Generation ePCR in Action

Designed specifically for EMS agencies using a wealth of real-world experience, ESO Electronic Health Record (EHR) is on the cutting-edge of ePCRs. ESO EHR includes a suite of powerful and easy-to-use software tools that enable complete and accurate clinical documentation. ESO works closely with its EMS partners to meet all training, deployment, and update needs. Built-in analytics make reporting more efficient than ever, while the ePCR software itself is intuitive and fun to use.

Watch an intro video now to see how ESO EHR is revolutionizing clinical documentation in the field.

Contact ESO today to schedule a demo.

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