Administration and Leadership | Operations | Slideshow

Improving PCR Documentation Presentation by Steve Wirth at AAA

01 / 19

Documentation Tips for Better Patient Care Reports

Steve Wirth stressed that EMS providers have to be very objective and never subjective when documenting and writing narratives.

02 / 19

Documentation Tips for Better Patient Care Reports

Steve Wirth stressed that EMS providers have to be very objective and never subjective when documenting and writing narratives.

03 / 19

Documentation Tips for Better Patient Care Reports

Steve Wirth stressed that EMS providers have to be very objective and never subjective when documenting and writing narratives.

04 / 19

Documentation Tips for Better Patient Care Reports

Pain is a good good example of where crews often do a poor job of documentation. You will see the poor description on the left as compared to a very detailed and accurate description on the right.

05 / 19

Documentation Tips for Better Patient Care Reports

This slide highlights inconsistencies in different parts of the anatomical view of the patient.

06 / 19

Documentation Tips for Better Patient Care Reports

Documenting the reason why procedures are performed (with objective observations) is critical.

07 / 19

Documentation Tips for Better Patient Care Reports

Steve Wirth noted that we're all in this business to deliver optimal patient care on an equal basis to all patients.

08 / 19

Documentation Tips for Better Patient Care Reports

How would you like it if someone wrote this after treating your grandmother?

09 / 19

Documentation Tips for Better Patient Care Reports

It's important that patients be treated equally and that we document them equally. By stripping away judgement, you become more empathetic.

10 / 19

Documentation Tips for Better Patient Care Reports

Steve Wirth gave a special shout out to Randolph Mantooth for this great quote presented at a recent conference.

11 / 19

Documentation Tips for Better Patient Care Reports

This slide represents what AJ thought was probably one of the most valuable points he heard made at the AAA annual conference: crews should have a patient-specific conversation after they get back to their post or headquarters.

12 / 19

Documentation Tips for Better Patient Care Reports

A post-call debriefing is critical to helping providers be better clinicians and improve documentation of patient care.

13 / 19

Documentation Tips for Better Patient Care Reports

Although experience is critical, we actually learn from reflecting on that experience.

14 / 19

Documentation Tips for Better Patient Care Reports

Plus/Delta debriefing is simple and immediate. It helps facilitate a conversation about what providers could have or should have done differently or, equally important, what they forgot to document. This not only allows providers to deliver better patient care in the future, but also is an opportunity to append and notate on the patient record if they forgot to include important information.

15 / 19

Documentation Tips for Better Patient Care Reports

It's important that we remember we are professional practitioners, and as EMS professionals it is our duty to question and reflect on the work we do in the field.

16 / 19

Documentation Tips for Better Patient Care Reports

Using tongue-in-cheek humor, Steve stressed the role of supervisors have in ensuring objective and complete documentation: "Good managers can't look the other way when errors are being made."

17 / 19

Documentation Tips for Better Patient Care Reports

The first thing agencies have to do to get on the right track with documentation is establish the right attitude, from the field providers to supervisor to management.

18 / 19

Documentation Tips for Better Patient Care Reports

A positive attitude, where post-call briefing is the norm and objective documentation is the rule, is critical to providing excellent patient care, high levels of pateint satisfaction, and high-quality documentation ... that won't result in lawsuits!

19 / 19

Documentation Tips for Better Patient Care Reports

EMS attorney and educator extraordinaire Steve Wirth used his powerful voice and lots of emotion to drive home his important documentation tips during his presentation on improving patient care reports at the annual meeting of the American Ambulance Association on Saturday, September 8, 2018.