Whether it’s confusion over medical necessity, proper PCR documentation, or signature protocol, EMS agencies regularly struggle with the complexities of documentation. More importantly, crews aren’t always trained on the importance of narratives, which can have downstream impacts on both the patient and the agency.
In our latest webinar, Digitech Head of Compliance Amanda Stark sat down with EMS Director Jim Duren of the Palo Alto, California Fire Department to talk about common documentation challenges, best practices, and the importance of building a culture where prioritizing quality documentation is the norm.
Quality documentation is part of patient care
One of the key points made during the discussion was that patient narratives represent far more than obligatory paperwork. They can have a direct effect on whether a transport is reimbursed, and whether a patient gets unnecessarily charged.
“When we think not only from a billing perspective, but from a patient care perspective, part of taking care of that patient is not sticking them with a bill that they don’t deserve,” said Amanda. “Tying documentation into patient care is something that doesn’t always get pulled into this conversation and probably should be.”
“The quality of your documentation reflects the quality of patient care that you provided. It’s your calling card in a sense,” agreed Jim. “So even if you did a wonderful job, if you just wrote a one- or two-liner and checked off a few boxes along the way, it’s not reflecting what you actually did for that patient.”
Detailed narratives also provide legal protection
In addition to providing an accurate account of care given to a patient, Amanda pointed out that strong narratives also provide vital information in the case of a legal dispute or litigation down the road.
“While it’s true that documentation is the basis for any reimbursement for transport, it’s also the legal record of what occurred. If there was ever any dispute about what happened, whether it’s the clinical care involved, a crime, or a motor vehicle accident, they may need to refer back to the PCR as a legal document,” she said. “It’s a very important piece of information; not just the data fields, not just the demographics. It’s the narrative as well, the signatures, the entire piece.”
While dropdown menus, checkboxes, and AI have improved efficiency in PCRs and helped expedite portions of run reporting, both speakers noted that something has been lost in the process. In his role as an expert witness, Jim sees this when reviewing a case, typically when there is bodily injury involved or some type of lawsuit.
“One of the things I’ve seen over the years is that narratives went from a SOAP type report down to one or two sentences on the ePCR that reference, see the flowchart, followed county protocol, and so forth,” he said. “There are glaring gaps in patient care assessment. Was the patient critical? Did you take vital signs every five minutes? Do the vitals match your assessment? Did you clearly document any changes? All of that is good documentation and is part of the medical-legal record that can be pulled up sometime in the future.”
In a police incident, he added, body cam footage becomes part of the equation as well. When that footage doesn’t represent clearly what is noted in documentation, there is a large gap in the incident record. Given that run records and narratives might be revisited three or five years down the road, after thousands more transports have occurred and memories have faded, it’s vital that details be captured thoroughly and accurately.
Signatures are non-negotiable
No discussion on EMS documentation would be complete without including patient signatures. Not an after thought or an optional ask—patient signatures are a critical part of EMS documentation, ensuring the record meets legal requirements, and the claim is eligible for reimbursement.
Amanda stressed that no signatures should be completed by crew members or anyone else other than the patient just to check the box.
“I think some of it is a lack of understanding; a crew member thinks I was told I have to get a signature and if I don’t, I’m going to get in trouble. But committing fraud is a way bigger problem,” she said. “Knowing the rules but also understanding the ‘why’ behind them helps in those moments.”
In addition to patient signatures, Jim said, adding that at his agency he stresses the importance of getting a witness signature when a patient refuses transport. “Someone watched and knows that you explained [the risks of refusing transport] to the patient, the patient understood it, and the patient signed that they understood it. They witnessed the whole process; that will help mitigate any litigation further down the road.”
Creating a culture of communication
Amanda and Jim agreed that for EMS agencies looking to implement and sustain strong documentation practices, leadership needs to set the tone. More than simply enforcing protocol, this includes explaining the importance of complete documentation including thorough narratives in terms of patient care and reimbursement, demonstrating how and when to capture a patient’s signature, and allowing for mistakes.
“It can be a fast-paced environment moving from call to call—you may make a mistake and forget to write something down,” said Amanda. “You want to set high expectations and create an environment where everyone understands the importance of compliance and the importance of good documentation. But you also want to allow room to be human and for accepting constructive criticism.”
Jim emphasized that when it comes to creating that type of open and communicative environment in the department, captains have a vital role to play.
“In our department, we hold to the idea that captains are responsible for their shift or their crew—and for the body of work that they do. So, our captains review the care reports of the providers on their crews,” he said. “Then, when we do run reviews, we bring in all the crews, captains, battalion chiefs, all units who were on scene. We put the run report up on a screen so everyone can see the work, and we go through it line by line to check it.”
To catch more of Amanda and Jim’s insightful conversation, plus hear them answer questions from attendees, check out the webinar on demand.
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