The accuracy depends on each piece of information on the report:
Being comprehensive, yet precise and to the point.
Report what you see, do, hear, smell, and feel as long as it is pertinent and relevant to your patient care
Make sure each area of the report has been filled out completely.
Look, we all hate extra steps and boxes to check, and YES if you don’t fill out certain boxes you will still be able to close the report and submit it. However, in the end, the report will either come back to you, your service will not bill the patient as much as should have been, or payment will be delayed while someone is trying to figure out what you should have done. Either way, take the time to completely fill out the report so everyone is happy and more importantly, you patient is properly cared for!
Now lets face it…some of us can read chicken scratch better than we can our own hand writing!
Think about this…3 years and hundreds, if not thousands of calls later, this will be the only way we can recall some of this information if we go to court. Take an extra minute or two to PRINT the document and make it legible. You will appreciate it later on!
NOT TO MENTION: Some people actually get subpoena's JUST TO READ THE ACR…because nobody else can make it out! A legible ACR can save you an unnecessary trip to the court house or lawyer’s office.
OK….OK….stop throwing stones at me and hear me out!
Yes, some of us can’t spell to save our lives! (Thank God for spell checker!) Matter of fact, I remember we used to literally dig through the PCR (Pre-HIPPA of course) pile to see if particular people had submitted reports. We would literally have guys come from all over the station to hear the newest “MAD LIB” report. We read aloud each of the reports. Sometimes as many as 3 or 4 times. At first we thought this guy was working in a new age ambulance with equipment only available to him. His ambulance had cafaters, spin broads, ocksagen, butatrols, epenefren and a variety of other unusual items. To this day we have yet been able to find any of these on the other units!
OK…sorry I digressed! But seriously, your report is a reflection of your professionalism.
Heaven forbid you are facing a “Johnny Cochran” wannabe when your report is called into evidence. An attorney that is trying to get your PCR or your testimony thrown out or at least, make it look bad, will JUMP all over poor grammar and spelling and any other nit-picky item he/she can find that will cause the jury to question your credibility.
Ever heard the term “Reasonable Doubt?” If not, just wait for your turn at jury duty.
OH…and while I’m at it….make sure you take time to write a descriptive narrative on all your calls.
Have you taken the time to look at and compare print-outs of your electronic call reports? They are all practically IDENTICAL. Aside from the patient specific information, these reports may not be as easy for you to recall specific information from the call without a detailed narrative.
Documentation should be completed ideally before the paramedic handles other tasks. Especially additional calls or patient contacts
Trust me, if you have never had one of those days where it is one call after the other, just wait, you will! And then when you are finally writing the first report of the last five calls, it will go something like this: “Was his blood pressure 150/90 or 160/90 and was the pulse 90 or 80?”
No big deal either way right?
What if the patient is an elderly patient who fell? Your original vitals were 160/90 p. 80 the hospitals vitals 30 minutes later was 170/84 p. 70, and again 30 minutes later 184/70 p. 60. Is it significant now? If you think not, try reading information about cushings triad and intracranial pressure.
All mistakes have a single line drawn through them then date and initial the change(s)
Mistakes should be corrected prior printing or submitting
Corrections after submission:
Your computer program vendor should have a method in place for correcting errors while still tracking the changes. Printed copies at facilities should be corrected just as a traditional ACR with single line and initials.
Free of non-professional/extraneous information
The previous methods are just a few of the many different methods used to record patient narrative information. You may use a different method for documenting or you may use different versions of the same (CHARTE, CHARTED, Etc.) versions. What is important is that the method used helps systematically approach the documentation so all pertinent information has been captured. With the proliferation of electronic ACRs, more and more documentation is becoming a simple click to check the box. These electronic ACRs are being set with “rules” that force you to record pertinent data before you can “close” the call, helping you more completely document the call.
Documentation is a maligned task in EMS, but one of the utmost importance for a variety of reasons. A professional EMS provider appreciates this and strives to set a good example to others regarding the completion of the documentation tasks.
Don’t be one of those who are constantly called to the boss’s office to read, correct, or update and ACR!