Paper to plastic: A perilous transition to electronic PCRs
Waiting to complete an electronic patient care report, long after the call, compromises its importance to the patient and the EMS provider
When I speak to EMS providers I am asked lots of questions about the legal issues associated with patient care reports (PCRs).
I cover the most important elements, such as being thorough and objective, and of course, completing prehospital care documentation promptly; that is before you leave the hospital for patients who are transported or before you release the patient when there is no transport.
“That’s not possible for us,” one provider recently told me. He explained – much to my amazement – that his workplace recently transitioned from paper PCRs to electronic PCRs (ePCR) and that they complete all reports at the computer back at the station.
He told me that as they run a call, they jot notes on a sheet of paper, transport the patient to the hospital where they leave a copy of the hand written notes, and then they go back to the station to actually write the ePCR.
“What if you get another call on the way back to the station; before writing the report on the patient you just left?” I asked.
He explained that it happens all the time; they run the next call and the next and the next and it can be hours before they make it back to the station to write the PCR on the first patient, as well as all the others who followed.
When I realized he was serious, the lecture came to a screeching halt and all of my attention was focused on this new insanity.
From a legal perspective – as well as a patient care perspective – there are almost too many things wrong with that process for me to name them here.
Documentation is for continuity of care
First, while it serves many functions, the ultimate purpose of prehospital care documentation is for the continuity of care.
Let’s take an unconscious patient for example. If a complete PCR is absent and the providers are long gone, how can the ER staff possibly have an adequate picture of what happened to the patient and what was done prior to their arrival?
Continuity of care was just defenestrated, which means tossed out the window.
“We leave a sheet of notes for the ER,” the medic explained.
After a few follow-up questions, we learned that the note sheet pretty much contains a list of medications, allergies, medical history, initial vitals, and the patient's chief complaint. No substantial narrative. No detailed assessment findings. No response to treatment, in fact no significant treatment at all.
I challenge anyone to argue that this constitutes adequate, much less excellent, patient care.
Recency ensures accuracy
Second, memories fade but the scars still linger (thank you, Tears for Fears).
Given the dynamic and high-adrenaline nature of EMS, how can any provider be expected to fully remember and correctly document essential and unique details from three calls ago?
It is certainly not uncommon to run back-to-back chest pain calls. Consider how easy it might be to transpose signs or symptoms from one patient to the other. Then consider how doing so can not only harm a patient, but also a provider when that incorrect narrative is projected onto a giant screen in court.
Contradiction or incompetence; don't choose either
Third, and no less important than any other, is the perceived (or even actual) loss of credibility in court – or elsewhere – when the note sheet left at the hospital does not match or even contradicts the narrative written later at the station. Such differences are the stuff of dreams for attorneys on cross examination. Attributing the mistake to confusion after multiple calls or a time gap only adds incompetence to that lack of credibility. As we say in the law: good luck with that.
Let us not forget the non-transports and AMAs. If the report is not completed and the patient only signs some detached generic release, then to what warnings and advisements are they actually agreeing?
Do it right or don't do it all
When I asked the medic why they do it the way they do, he explained that the reasons were purely financial; the department could not afford to put mobile data terminals or tablets into each unit, but they wanted to use an ePCR.
If you cannot afford to do it right, you cannot afford to do it at all.
Whether paper or plastic, patient care reports are for patients. If the PCR does not readily provide for the immediate continuity of care; if they do not adequately serve the patient then they are really of no use. As a tool for protecting providers, if they undermine your credibility in court, then they are really of no benefit to you either.