This course can be used in initial education, continuing education, and EMS continuous quality improvement. The purpose is to set a standard of what is expected for a complete patient care record.
Rational:
A major weakness for EMS providers is creating complete and accurate patient care records. Establishing a method of review and grading at all levels of an EMS providers career is pinnacle for patient care, EMS billing and EMS data management for decision making regarding the future of EMS.
Objectives:
After completion of this course the student will be able to:
1. Explain to a student or EMS provider the importance of a complete and accurate patient care record.
2. Define validity of a standard measure.
3. Define reliability of a standard measure.
4. Identify the sections of a patient care record that should be completed by students and EMS providers.
5. Determine the appropriate scoring weights for each section of the PCR rubric.
6. Assemble a complete rubric for evaluation patient care records for students and EMS providers.
7. Calculate a final score based on the weights assigned.
Outline:
1. Introduction
2. Why is it important to have a metric measured the same way every time.
a. Validity and reliability
i. Removal of bias
ii. Making the subjective objective
3. Discuss the importance of a complete and accurate ePCR
a. Patient care issues
b. Billing
c. Data
d. Legal challenges
4. How do we impart that to students and EMS providers
a. Discuss methods to obtain buy in for each portion of each concern area:
i. Patient care issues
1. Describe the benefits
ii. Billing
1. Describe the benefits
iii. Data
1. Describe the benefits
iv. Legal Challenges
1. Describe the benefits
5. Determine the weight of the rubric based on the area you are concerned with (rational for the review):
a. Patient care
i. Protocol Compliance/Treatments
b. Billing
i. We want to get paid correctly
c. Data
i. Is the ePCR complete
1. Agency
2. MCA
3. MIEMSIS
4. NEMSIS
d. Legal challenges
i. Will the ePCR stand up to scrutiny
e. Balance between all
i. I need to make sure it is all good
6. Anatomy of an ePCR
a. Demographics
b. Times
c. Clinical Impressions
d. Medication/History/Allergies
e. Vital signs
f. Flow Chart
g. Assessments
h. Treatments
i. Medication Dosing
j. Narrative
k. Specialty Information
i. Stoke, cardiac arrest, trauma etc.
l. Incident location and details
m. Personnel information
n. Insurance
o. Disposition
p. Signatures
q. Ancillary paperwork
i. Medication exchange
ii. EKGs
iii. Etc.
7. What sections are important for your review?
a. Create a list from least to most important for the type of review you are completing.
i. Patient care
ii. Billing
iii. Data
iv. Legal challenges
v. Balance between all
8. Assign scoring based on the list of most important to least important.
a. Example
i. Legal challenges
1. Times match and are apropriate
2. All ancillary documents are present and their time match
3. Narrative makes sense without spelling error
4. Factually accurate
9. Transfer that list with scores to a rubric
10. Calculating a score
11. Tweaking it to perfection’
a. Evaluation of the tool
i. Is it doing what it was intended to do
1. Are ePCRs improving
b. You may find that a subjectively garbage report may get a good score
c. Have others look at it
i. Peer review
d. If it is found that the rubric isn’t working properly adjust it. Don’t get rid of it.
Speakers 
EMS System Manager, OCMCA
John Theut has been in the EMS and fire services profession for 30 years. He retired from the Ferndale Fire Department as a Shift Captain and EMS Coordinator. Currently, he is the EMS System Manager at the Oakland County Medica Control Authority (OCMCA). He is also the Program...
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