Ensure Proper Clinical Handover with Quality Patient Care Reports
To prepare quality patient care reports for smooth
patient
transfer,
emergency
medical staff need to adhere to some important considerations.
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Proper communication among clinicians is crucial to prevent adverse events in healthcare and medical transcription companies play a key role in ensuring this with accurate and timely documentation. This is all the more critical when it comes to emergency medical services (EMS). Paramedics or EMS staff need to prepare detailed emergency care reports (ECRs) to provide downstream healthcare providers with a clear idea about the patient’s needs. This is necessary to improve the quality and continuity of care. The Journal of Emergency Medical Services (JEMS) Magazine recently published a 5-part series on how emergency staff can prepare goodpatient care reports (PCRs). This article summarizes the key points. The Five Criteria for Well Written PCRs EMS staff need to go by five criteria to produce comprehensive PCRs: •
Collect all necessary information
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Avoid vague terminology
•
Justify the medical interventions reported
•
Provide a detailed narrative
•
Ensure legibility of signatures and hand-written information
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Collect all necessary information: PCRs should contain the following details: -
Detailed dispatch information to validate the reason and level of response
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Patient demographic information
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Patient insurance coverage details
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Chief medical complaint upon arrival and when symptoms started
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Detailed primary and secondary assessment information based on symptoms communicated during the assessment and clinical findings
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Full information about medical procedures performed and the results
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The EMS staff’s impression about the patient’s condition
Avoid vague terminology: To provide a clear clinical picture of the signs and symptoms of the patient at the time of transport, avoid using vague terminology in the PCR. The aim should be as specific and descriptive as possible. Values of assessments of blood pressure and glucose levels should be provided.
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Justify the medical interventions reported: This is important for the continued care of the patient as well as to reduce denial of claims. It is necessary to report the
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medical procedures performed clearly, explain why they were performed, and provide details aboutthe assessment, any changes in the patient’s condition, and the outcome. •
Provide a detailed narrative: The narrative for the PCR shouldinclude a detailed explanation of medical necessity and why transport by EMS was required. Medical monitoring of the patient and secondary exam performed during transportation to the hospital should also be provided. EMS staff should report the patient’s symptoms and interventions to manage the symptoms.
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Legibility of signatures and hand-written information: Patient and provider signatures in the PCR should be legible. If signatures are not legible, the name should be printed or typed in the report. If the patient is unable to sign the report, a family member should do so. The report should also have crew members’ physical and/or electronic signatures and credentials. The person who receives the patient at the healthcare facility should also sign the PCR. Any handwritten notes and forms attached to the PCR should also be clear and legible.
The main concern of paramedics is to provide proper patient care in emergency situations. Outsourcing medical transcription helps them focus on their primary tasks and ensure quality PCRs. Partnering with an experienced medical transcription company that has skilled medical transcriptionists on board will allow EMS providers to craft robust, accurate electronic PCRs, avoid omissions or delays in documentation, and ensure proper patient transfer.
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(800) 670 2809