A new model for writing effective patient care reports

The shift to electronic documentation demands a shift in ePCR documentation practices


By Elizabeth L. Angeli, Ph.D.

Think back to your EMS training. Chances are you, like me, were told to paint a picture, tell a story, or to follow CHART or SOAP mnemonics to ensure you capture details of a scene, creating effective, powerful stories in patient care reports so that no pertinent detail is left unnoticed.

But, despite their ubiquity, these report-writing methods have not lead to the effective, detailed patient care reports as hoped. EMS leaders continue to outline the consequences of poor documentation practices and recommend that providers include more detail, be specific and write clearly. Part of the challenge is that these recommendations are outcomes of improved writing, and although important, they are not a means to achieve improved writing.

The PCR has become more than a picture; it is a sustained, data-driven argument that persuades readers that effective patient transport and treatment was provided. (EMS1)
The PCR has become more than a picture; it is a sustained, data-driven argument that persuades readers that effective patient transport and treatment was provided. (EMS1)

Why PCR writing is hard

As a workplace writing specialist and EMS researcher, I study EMS writing practices and how to improve them. Unsurprisingly, most of my participants share with me that documentation is the most dreaded and one of the most challenging parts of the job.

Yes, writing is hard, and it has become harder in part from the shift in paper documentation to electronic documentation. The paint a picture method of documenting was implemented when providers charted on paper, and these methods do not account for the countless data points a provider is required to gather and remember during a response.

Now, in an age of evidence-based medicine where data reigns, documentation needs to serve many purposes for many audiences (e.g., lawyers, insurance, doctors, medical directors), and electronic formats contain multiple drop-down menus and text boxes, which mean hundreds of potential data points make up the PCR. The PCR has become more than a picture; it is a sustained, data-driven argument that persuades readers that effective patient transport and treatment was provided.

But with this shift in writing practice usually comes a change in how we teach writing. Current models, like SOAP and CHART, don’t tend to the writing process, but instead focus on the product, the PCR. That is, these models tell providers what to include – subjective, objective, assessment, treatment – and don’t prompt providers into thinking about how to gather all of that information and why it’s important.

The IMRaD model for patient care reports

One answer to this challenge is a new model for writing: the IMRaD approach. An IMRaD (pronounced “em-rad”) report is a recognized and valued writing format in medicine, and it both tells providers what information to include in the report and helps providers engage their writing process by considering the pieces of evidence and data that PCR readers will value.

Traditionally used in science labs, IMRaD reports present methods and results from conducted research, like experiments, and persuade readers that the research is accurate. These reports follow a specific structure that presents information in a logical order that omits unnecessary detail, much like EMS providers hope to achieve when painting a picture in the narrative. The general IMRaD structure is as follows:

  1. Introduction. Introduce the reader to the document, often including brief background information about the document and the document’s purpose.
  2. Methods. Detail the process the writer followed to complete a task. For example, in a laboratory setting, researchers include the specific steps they take to complete an experiment. This section allows the document’s readers to repeat the experiment, providing a mechanism for replication, which is crucial in technical fields.
  3. Results. Present the findings – or results – that were garnered from the methods taken and interventions provided.
  4. Discussion. Explain what the findings – or results – mean given the larger context of a document.

When applied to EMS writing, the response can be seen as research in a lab – investigating a scene to determine a problem and intervene. The PCR, then, becomes the IMRaD report that illustrates the problem to readers and what was done to solve it.

For EMS, the IMRaD structure looks like this:

Introduction

  1. What did you observe in the scene size up?
  2. What information did you gather, including vitals?
  3. What did you see, hear, touch or smell that led you to choose a particular protocol?

Methods

  1. What protocols did you follow? Why?
  2. What treatment did you render? Why?
  3. Did you transport the patient? If not, why not?

Results

  1. What was the effect of those treatments?

Discussion

  1. Is there anything else that you need to add to support your methods and results?
  2. Would anything be useful for the insurance companies, other healthcare providers, a lawyer, etc. to know if they read this PCR?
  3. Did anything feel off or funny? Did you have a gut feeling about something that the patient might need help with aside from EMS care? This question can be useful if something is observed that could lead to other services being called in, such as observing unsafe living conditions.

If EMS professionals follow this model in their narrative portions of a PCR, their mindset shifts from telling a story to detailing the results of data collection, which is, in short, the work of a response:

  • To gather visual data and evidence.
  • To choose a method of treatment and transport (and if transport is refused, the data to justify that decision is needed).
  • To explain the effect of those decisions.
  • To include anything else that will help readers of the PCR take action.

How IMRaD improves PCR narratives

Focusing on the methods of report writing, like SOAP or CHART, is important because they become genres in which providers write. Genres are a specific type of communication or format, like a sci-fi movie, and they are powerful tools that create expectations for readers. For example, if you see an action movie, you will have certain expectations: you’ll expect to see certain actors and a multitude of stunts and special effects, and you’ll expect to be entertained.

These same expectations apply to written genres, like text messages, email and reports. When people read them, they bring expectations and values with them, many of which have been outlined in EMS report writing guidelines: include detail, be specific, write clearly, and avoid grammar and spelling mistakes.

However, when educators focus solely on these aspects of writing, they focus on the outcomes of writing, not the processes that writers engage in to meet genre expectations of effective documentation.

As a genre of writing, the IMRaD model complements the paint a picture method. The IMRaD model guides writers to make a sustained argument that is driven by evidence and that justifies treatment decisions. In detailing that argument, writers paint a picture that persuades readers that their actions were justified. The IMRaD model combines the importance of writing an effective medical legal document with questions that engage a provider’s writing process.

It’s time that writing practices in EMS training align with the changes in writing technology. EMS has moved beyond writing a one-page report, and training courses need to help new providers with this shift, telling providers to write a data-driven argument that, in turn, paints a persuasive picture.

About the author

Elizabeth L. Angeli, Ph.D., is an assistant professor in Marquette University’s English Department, where she studies and teaches workplace writing and rhetoric with a focus on EMS. Her research has been published in journals such as “Written Communication” and “Journal of Technical Writing and Communication,” and her new book, “Rhetorical Work in Emergency Medical Services: Communicating in the Unpredictable Workplace,” details the underlying persuasive, cognitive and collaborative processes that guide EMS communication and decision making. Liz received her Ph.D. from Purdue University and has held a National Registry Emergency Medical Technician-Basic certification.

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