Documentation & Patient Care Reporting, Exclusives

New Documentation Mnemonic and Rubric Substantially Improved Documentation Performance

The objective was to evaluate the performance of a newly-developed mnemonic for documentation, an accompanying evaluation rubric and to improve compliance with documentation of patient care report elements.

Introduction

EMS documentation is an essential element in the continuity of patient care. EMS training has taught us if it was not documented, it was not done. Hospitals use EMS documentation as a way to continue the care provided in the field by EMS providers. This state medical record must be accurate, have correct grammar, no misspelled words and clearly describe the patient’s complaint, treatment and outcomes. 

For example, to ensure that an organized system of trauma care evolves and improves over time, there must be a mechanism for continued system review to ensure protocols are being followed, that sources of error are identified and addressed and recurrences are prevented. Current recommendations by the American College of Surgeons Committee on Trauma (ACS-COT) include a performance improvement (PI) process, which describes the continuous evaluation of the center and providers through structured review of the process of care and patient outcome.1–4 Laudermilch noted failure of EMS to document basic measures of scene physiology is associated with increased mortality.5

The development of criteria to standardize EMS documentation is essential to retrieving more accurate data and improving patient outcomes. This documentation should be attached to training of a new, systematic process of documentation that is objectively scored through a rubric. Be sure to note that rubrics should be well designed, topic specific (contextual), analytic and complemented with exemplars to be effective. The history of writing assessment shows that achieving high reliability in writing assessment is not easy, and we should be careful not to sacrifice validity to achieve higher rates of reliability.6  

Continuous quality improvement is a process that couples carefully identified, measurable performance indicators with information systems to monitor, analyze and trend data. Benchmarking outcomes with other EMS systems allows the identification of “best practices” and the evolution of standards. Emergency medical services professionals must actively participate with the broader health care community in creating performance measurements to ensure that high-quality care is delivered consistently.7

The objective of this study was to evaluate the performance of a newly developed mnemonic for documentation and an accompanying evaluation rubric. The goal of these techniques is to improve compliance with documentation of patient care report elements.

Methods

A descriptive method was used based on the development of a mnemonic, as a method for improving the process of recording patient care. An evaluation rubric was developed in conjunction with the mnemonic to assess documentation performance. Scores greater than 80% were deemed “passing,” and scores greater than or equal to 95% were classified as “high achievers: out of 100%. Training was conducted at a fire-based EMS agency in the fall of 2017. Beginning January 1, 2018, the EMS Committee supervised randomly reviewed one run report per employee per shift. The analysis was from January 1 to December 31, 2018.

Definition: D.O.C.U.M.E.N.T.TM

  • Dispatch/Demographics/Distance
  • On-scene Assessment
  • Chief Complaint
  • U Say What
  • My Eyes, My Eyes
  • Examination
  • N the Verdict Is…
  • Treatment and Transport and Decisions-Decisions

Results

In October 2016, a retrospective analysis was conducted using the rubric (instrument). The review was conducted prior to the implementation of the instrument, training or evaluation. Forty-three percent of patient care reports were reviewed in October 2016 (n = 122) using the rubric. Reports above the passing score (greater than or equal to 80% compliance) were 48%. Reports in the “high achievers” category (greater than or equal to 95% compliance) was 0%.

After implementation of the instrument 37% (n = 1,482) of patient care reports were reviewed. The reports with a passing score ranged from 85% in January 2018 to 98% in December 2018. Reports in the “high achievers” category ranged from 16% in January 2018 to 71% in December 2018.

In January 2018, one element (primary impression), had been documented 25/146 times (17%). This low outcome was partially due to their EMS education instructing them not to diagnose. Further training from the medical director was conducted and documentation for this element in February 2018. Primary Impression rose to 64%by March 2018 and improved to 84%by June 30, 2018. This element has held steady at over 90% through December 2018.

Limitations

This study was conducted at a single fire-based EMS agency. Future work is needed to assess impact at other agencies. Further prospective work is needed to confirm sustainability of observed improvements in this study.

Conclusion

Substantial improvement in the documentation of key patient care record elements was noted following implementation of the newly developed mnemonic (instrument) D.O.C.U.M.E.N.T. ™ and associated objective evaluation rubric. Future work is needed to assess the generalizability of these findings at other EMS agencies.

Note

This evidence-based research won the award for Best Poster Presentation at EMS World Expo in 2019 in New Orleans, Louisiana, competing against 30 other posters from around the world.

References

  1. American College of Surgeons, Committee on Trauma. Trauma Performance Improvement Reference Manual. Chicago, IL: American College of Surgeons; 2002.
  2. West JG, Williams MJ, Trunkey DD, et al. Trauma systems. Current status future challenges. JAMA 1988;259:3597–3600. [PubMed: 3373707].
  3. Bazzoli GJ, Madura KJ, Cooper GF, et al. Progress in the development of trauma systems in the United States. Results of a national survey. JAMA 1995;273:395–401. [PubMed: 7823385].
  4. American College of Surgeons, Committee on Trauma. Resources for the Optimal Care of the Injured Patient: 1999. Chicago, IL: American College of Surgeons; 1999.
  5. Laudermilch DJ, et al. Lack of Emergency Medical Services Documentation Is Associated with Poor Patient Outcomes: A Validation of Audit Filters for Prehospital Trauma Care. Journal of American College of Surgeons 2010; 2:220-7.
  6. Rezaei AR, et al. Reliability and Validity of Rubrics for Assessment through Writing. Science Direct. Assessing Writing 15 (2010) 18–39.
  7. Dunford J, et al. (2002) Performance Measurements in Emergency Medical Services. Prehospital Emergency Care(2002) 6:1, pages 92-98.