Enhance Quality Assurance Program for Trip Report Writing

Professional malpractice, management liability, patient refusal of care and/or transportation, dispatch errors, and failure to respond are all issues which should get your attention in today’s litigious society.  An Emergency Service Organization must understand how to address these issues in relation to Patient Care and Supplement Reports.   It is important to assure the utmost of professionalism when dealing with the issue of proper patient care documentation.  Quality assurance follow-up is essential to assure protocol and standing order adherence.  With aggressive involvement by Quality Assurance personnel, weaknesses identified in the evaluation process should trigger the Continuing Education Officer to develop a program to address system and patient care provider needs. 

After review of a small sample of your PCRs, we recommend consideration be given to establish guidelines for PCR review.  Ideally, all ALS level PCRs should be reviewed along with a sample of BLS level PCRs.  At minimum, the following PCRs should be reviewed 100%.

• ALS level reports requiring one or more ALS skill, intervention, or medication
• AMA/Patient Refusal (regardless of level of care provided)
• Airway management (oral/nasal airway adjuncts, blind airway insertion devices, intubations)
• Aeromedical utilization

All selected PCRs should, at a minimum be reviewed for the following elements:

• Legibility - Can the report be easily read?
• Patient Management - Were there any problems or irregularities noted?
• Medical Protocols - Were protocols followed?
• Scene re-creation - Can the scene and treatment be created without questions or assumptions?
• Vital signs - Were at least two sets of vitals obtained and recorded with time stamps?
• Transport - How did you move and secure the patient
• Transfer of care - Transfer to another EMS agency or to hospital staff
• Unusual events - Document anything out of the ordinary

Available Resources

• Patient Care Documentation