You Entered The Facts, Now Tell The Story!
A recent online post announced one of the latest artificial-intelligence (AI) based report writing programs. It indicated that a standardized format narrative could be generated, based upon the input provided, free of “hallucinations” and subject to your approval. On the surface, this sounds like a useful tool to relieve much of the report writing burden.
Documentation is one of the less “sexy” parts of the business while also serving as one of the most important. Regardless of the care that you provide, the only record besides your memory that will be available if a case goes to court, which generally does not happen for a few years, is the patient care report (PCR). Since most by far are now in electronic format, ePCR is the contemporary reference.
Check Your Work
The “subject to your approval” part stood out boldly. Having reviewed thousands of reports, it’s apparent that those which have been manually written are often not initially checked for errors or thoroughness, making it unlikely that automatically generated ones will consistently be. If there are shortcuts to be found, some providers will discover them.
As National EMS Information System (NEMSIS) requirements evolve, so do the mandatory fields on the ePCR. Most programs will automatically flag deficiencies in these fields. While a large amount of the data is based on NEMSIS requirements, other entries may be either agency or system generated. It has become somewhat common to rely on eliminating the flags as a sign of a complete report. It’s not. These represent the facts of the call but not your version of the events.
Tell Your Story
The narrative is your story that is (hopefully) written while it’s fresh in mind. Remember that court cases often take years to go to trial. Even depositions don’t always occur in a timely manner. If your unit is relatively busy, most individual calls likely won’t stand out in your mind later. It is good practice to keep a small notepad in your pocket to document certain observations if you get busy so that calls don’t blend.
There are many reasons for accurate and personalized documentation. Some providers have prewritten standard outlines and may just fill in the blanks. While this can lead to consistent and familiar reports, it can also raise questions regarding individualization. In a busy system, it wouldn’t be unusual for an attorney to obtain two of your reports. It’s not a good reflection of your concern for accuracy if they appear remarkably similar.
While your care may not be an initial legal target, avoid becoming “collateral damage.” A lawsuit may seek damages for an injury resulting from poor maintenance, but a questionable report or uncertainty about the care provided opens the door to question your actions. Ensure avoiding a potential situation where your report is blown up on a large screen in a courtroom while you receive a virtual colonoscopy.
PCR Importance
Regardless of format, patient care reports serve several purposes. They are legal documents and your only official record of the care that you did or didn’t provide along with justification of your actions, especially if they deviate from the agency guidelines as approved by your medical director. Reports also justify the need for EMS transport at the time of call. While billing and reimbursement is never a priority over care, it might help to support your continued employment and potential service expansion.
There have been numerous articles written about proper documentation and that isn’t my intent here. It’s imperative that you develop and refine your own style of writing. A good summary of the narrative is that it should be written so that you, a supervisor, medical director, or attorney can place themselves at the scene at a later date and understand what you faced and how it was dealt with.
While highlighting pertinent facts, especially unusual response, scene, or patient circumstances, is important, merely repeating less important facts that have already been entered is not only unnecessary, but may lead to contradictions. A common report writing shortcoming involves poor spelling or grammar. It’s always a good idea to have another crew member review your report for thoroughness and accuracy; this is even more important if your writing often contains errors. Even if your care was excellent, a poorly written narrative won’t reflect it.
Customize Each Report
Documentation is part of the EMS curriculum, regardless of your certification level. While there are standardized formats that have existed for years to help ensure a complete incident record, many were developed prior to the proliferation of tablets with ePCR programs. That was another item that stood out in the original referenced post. As previously stated, merely repeating less important facts that have already been entered potentially opens the door to discrepancies.
While you should have learned report writing during initial certification training, it may have been presented based on the favored opinions of the instructor. There are numerous talented and effective EMS instructors. Knowledge and experience are important traits for an educator but the ability to connect with their audience is equally valuable. Unfortunately there are some who may largely be in their position based on ability as a provider, familiarity with the program director or having a convenient schedule. This is another reason to develop your own style while incorporating that of several other more experienced providers.
While many incidents may seem fairly routine and only require simple documentation, more complex ones demand in depth reporting. An important note is that your most detailed narrative must be written for a patient who refuses all efforts to obtain treatment for an acute medical condition that clearly needs prompt attention. Once you think a report is complete, read the entire draft to ensure that all of the pieces that you entered completely solve the puzzle without gaps.
Learn in Spite of Your Training
For the aforementioned reasons and more, all instructors are not created equal. Much of your learning path will consist of self-discovery while learning who to emulate and what to avoid. Contrary to the popular expression, PowerPoint does not kill any more than lights and sirens do. They can both be effective tools if used properly.
A quote attributed to Albert Einstein states that “if you can’t explain it simply, you don’t understand it well enough.” The instructor who uses big words or merely reads slides probably doesn’t understand what is being taught well enough to make you understand. The method that you were taught to write reports may not be pertinent to the current circumstances of your position.
AI is a Tool, Hopefully You’re Not
AI is a relatively recent tool that may assist with several aspects of emergency care. Like many other tools, it may have benefits in supplementing our abilities but shouldn’t be used as a replacement. Remember that you were at the scene of the emergency and cared for the patient until turnover while AI was not. Even recent advances that are combined with body cameras don’t have peripheral vision. Only one of you can properly assimilate the whole experience and tell your story.
Artificial intelligence may be a useful aide but is not a substitute for the real thing. Use your own to learn and continuously progress as a provider. Ignorance is the breeding ground for stupidity.
