Saving lives is no easy task, but Emergency Medical Services (EMS) providers are entrusted with doing just that, and due to the critical nature of their day-to-day operations, rigorous protocols must be in place to ensure deficiencies are properly addressed.
In their field, that means EMS providers must carefully document each step of their processes to ensure that their results can be validated against long-term goals.
Handling documentation can be complicated, especially when just starting out, so for those who want to deliver the best EMS services possible, it’s essential to be aware of some of the most common documentation mistakes and understand how to avoid them.
Why Is EMS Documentation Important?
Proper EMS documentation requires a record of care, which details everything from their initial contact with a patient until that transfer of patient care. Having a record of care for response management makes it easier to look back at how certain problems were handled to determine whether core commitments were met.
Resource use, training protocols, and management decisions should all be carefully documented to eliminate inefficiencies and obtain better results. It’s also important for liability reasons, as strict documentation is important for legal reporting.
What to Avoid When Doing EMS Documentation
Documenting everything right away is essential to get accurate results, especially for EMS services. The use of common methods to eliminate errors from the documentation process allows respondents to improve their response times, on-scene management, and quality of care.
With so much at stake, it’s vital that EMS organizations properly prepare their employees with adequate training, support, and documentation of their roles. Beyond that, EMS providers should take the time to ensure they’re comfortable with covering their documentation before doing it on their own.
There are quite a few things to keep in mind when documenting EMS services, but avoiding errors is easy if you know what to look out for, such as the following:
1. Failing to Document Mistakes
Frequent errors, hazards, and resource limitations should all be accounted for so that decision-makers can do something about them. It can be tempting to simply erase a mistake and start over, but it’s crucial that you do not leave anything out of your reports. Be open and honest in your reporting so supervisors can see and be aware of deficiencies before they cause further issues.
2. Waiting to Document
Another common mistake that those new to EMS services make is waiting too long to report things. It’s easy to forget things, and waiting too long can severely affect a worker’s quality of reporting. Misleading information can have drastic consequences, so it’s important that they write things down when they’re still fresh in their mind.
3. Have an Outline
It’s easy to make mistakes when completing similar, monotonous, and repetitive tasks. Employees that rush through these tedious aspects of the job are more likely to make mistakes, which makes it essential to have a solid plan of action before even starting the documentation process.
Things will be different in every circumstance, but using outlines and templates can make it easier to manage things and get them done without slipping up. Doing so also saves time, as much of the repeatable language and information can be simply reused.
4. Revise and Edit
Reporting mistakes are commonplace, so it’s important to go over everything thoroughly, at least once, to ensure that the information is as accurate as possible and to avoid the biggest errors.
Consistency and accuracy will make your documentation much more reliable, and validating data, fixing spelling and grammar mistakes, and considering the overall structure of the report will allow you to improve your documentation methods over time.
5. Be Thorough
When it comes to the field of EMS, you can never have too much information, but rookies often make the mistake of limiting the amount of information they report, not wanting to overwhelm the reader. However, for decision-makers, well-organized and thorough reporting is one of the most valuable assets available to them.
It’s important to document everything accordingly and ensure that references, receipts, and other relevant pieces of information are provided alongside it so that they don’t have to be hunted down later.
Proper Documentation Is Essential for EMS Workers
In any industry, documentation provides a paper trail that allows decision-makers to go back and look through operational data for relevant information. The ability to do so is especially useful for EMS organizations, where strict quality control standards are always enforced. For rookies, knowing what mistakes to avoid can ensure they grow into their role without developing bad habits.
Ensuring documentation syncs with company policies takes ongoing effort and a long-term vision. Looking at common areas of interest, limiting the potential for bad reporting, and offering support and communication for misreporting will add value to the organization and allow EMS leaders and workers alike to focus their efforts on helping the public.