Electronic Run Forms

We have a longstanding issue in our region with EMS not leaving run forms at the hospital. It has been going on for as long as I have been in EMS, but it has gotten much worse since the transition to electronic PCRs.

I have perhaps the most unique view of the issue here as I am a full time paramedic who has to write the run forms, a 70% clinical coordinator who has to chase down paramedics for their run forms as well as QA them, and I am also the trauma registrar, which means I have to access the forms weeks later to gather and enter data from trauma patients.

First, the good news, the EPCRs are legible and from the clinical coordinator position, they are great for QA as they are easy to access once they have been submitted. Now, the bad news. The electronic PCRs take too long to finish, and paramedics are left with the choice of finishing the run form or responding to another call. And sometimes when they do finish them, the printer is not working or the computer freezes and the form canít be run off.

As a paramedic, I do my best to leave a completed run form at the hospital before I leave for the next call. I often start the PCR on the way to the call, entering as much information as I can. Then, I enter information during the call. You canít really do this during a cardiac arrest, but it can be done on most EMS calls. I ask the patient, a question, I type the answer into the computer. Name, date of birth, social security number, insurance info, meds, allergies, medical history. Iíll enter the vitals and any interventions I do, along with which hospital we are going to and why, etc. Sometimes I can even do the narrative on longer or less complicated trips.

Occasionally there is talk of installing video cameras in the back of ambulances, and people have speculated what it will show. My guess is there will be lots of footage of EMTs and paramedics looking at their keyboards, instead of at their patients.

In triage, I keep writing, and will get the receiving hospital signature, along with the patientís if I have not already gotten it. Even with all that, though, on most calls, I still need to sit down in the EMS room and finish entering info. I enter only the bare minimum, but I do try to write as full a narrative as possible. I used to never leave until I finished the report, but that was largely when I was working as a contracted medic for the volunteer service. They didnít care how long I took at the hospital. Now that I am back in the city, I am usually the one being called out of the hospital to do the call in the volunteer town while the volunteer medic pecks away at her run form. Or I am being called out to a call in the city of another town.

Some argue you should never leave the hospital without leaving a complete PCR. The PCR is essential to the patientís continuing care. Others would argue the lady having a stroke in the aisle at Wal-Mart is more important than finishing the run form for the patient sitting in the waiting room with cold and flu symptoms, who you picked up three blocks from the hospital. I am clearly on the side of helping the lady stroking out.

We talk a lot about getting more funding for EMS. I know of one cheap way to help EMS. Allow medics to leave the hospital before completing their run forms provided they are able to fax it or deliver it to the hospital in a timely manner. If I do 8 transports in a 12 hour shift and it takes me 30 minutes to do each run form, that means 33% of my time is spent sitting in an EMS room. If I can cut that 4 hours down to one hour sitting in the hospital, then I have increased my productivity by 25%.
I donít hesitate to clear the hospital now and I am doing more calls because of it. However, there are still some calls where I always leave the run form — cardiac arrests, strokes, unresponsive patients Ė any call where I feel there is valuable information for the patientís continuing care that no one else can provide. But there have been times when I have received a status zero, holding priority ones page when I have cleared even those calls.

I am in favor (and it is being worked on) of having a required short form that can be filled out by hand and left on turnover. But I think the best way to fix the issue is to improve the reporting at patient handover. Too often, we give an oral report to a busy nurse, who may or may not remember the details when it is time to focus on the patient. And unless, the patient is critical, we hardly ever give a report to the doctor. A better more attentive oral report structure might lessen the need for the doctor or nurse to reference the written report later.

One final thought. I understand that the PCR is important to continuing care, and while it may seem like it is not read by the ED nurse or doctor, it is very valuable to other people in the hospital as well in the ICU or cardiology or orthopedic floors. But I would like to raise a question.

There is a statistic known as number needed to treat. For instance, with CPAP, the number is 6. What that means is for every 6 people, you treat with CPAP, you save one of their lives. What is the number needed to treat for leaving a run form before leaving the hospital? In other words, how many run forms need to be left before one left run form will save a patientís life or affect a certain outcome. Now letís look at the number needed to treat for ambulances being allowed to leave the hospital immediately following patient turnover and oral report as opposed to being required in all cases to stay at the hospital until the PCR is finished. How many people are being helped by having an ambulance available or a closer ambulance available? I donít know these numbers, but I would wager heavily that as far as patient outcomes, having the ambulances available far outweighs having the PCRs completed prior to leaving the hospital.

Here is our current regional PCR policy:

Documentation of Prehospital Care

Documentation of assessments and patient care shall be done on all patients evaluated including, but not limited to: emergency, transfer, patient refusals, downgrades and stand by circumstances.

Documentation of patient care shall be done immediately upon completion of patient care, and/or transfer of care. The only exceptions to this practice are personal safety issues.

The EMS Patient Care Report (PCR) is a medical record and the primary source of information for continuous quality improvement review. Prehospital care personnel shall be responsible for providing clear, concise, complete and accurate documentation. The prehospital provider who authors the report must include his/her name and signature on the report.

When a patient is transported, the PCR will be delivered with the patient to the hospital. Vital information should also be immediately communicated to the Emergency Department staff for efficient and safe transfer of care.

The PCR shall be left at the receiving emergency department. Every effort shall be made to be certain that the nurse/and or physician responsible for care receive the record. In the event the crew is called out of the hospital to respond to an emergency call, the run form must either be faxed to the facility immediately following the call, or hand-delivered. All PCRs must be left within eight hours.

Failure to leave a run form is considered to be just cause for disciplinary action.

Each emergency department shall prominently post in their EMS area their procedure for leaving PCRs. Copy machines will be made available to EMS. Hospitals may require a second copy of the PCR be left in a designated box for review by the hospitalís EMS Clinical Coordinator.

One last note on PCRs. Most services have electronic logins available for hospitals so the hospital clinical coordinator can look up any call at his desk and have access to the run form. No paramedic leaves at the end of the shift without finishing all his PCRs for the day. The PCRs get written, the question is more about timely delivery to the hospital.

6 Comments

  • Dan says:

    Hartford area hospital printers suck. They all get faxed PCR’s from me now.

  • Jay says:

    Where I precepted as a student, the service had lifepak monitors which plugged into the EPCR tablet and could transfer information directly to the EPCR fields – vitals, times, the whole nine yards. When you got to the hospital, the tablet plugged into a console that had an integrated, full-size computer keyboard that was used to type up the call, rather than using the also available (but very annoying/frustrating) tablet touch screen. Upon form completion, everything was electronically sent from the terminal to the database, and you were ready for your next call. Medics were allotted 15 minutes from arrival at the hospital to complete their PCR, and could only be sent back out on priority 1 or 2 calls during that time if their stretcher had been cleared. If so, the unfinished call got saved and could be uploaded when you brought the next patient in. The same terminals were found in every EMS base, too, and the system was 100% paperless.

    That type of system sounds like a great solution to your problem, if the funding could be secured.

  • BH says:

    All the services in our area with ePCRs (except one that’s a private) have printers in their trucks. State protocol says we don’t leave without leaving the copy.

    At our most common destination ERs, the nurse we’re talking to is assigned solely to triage incoming EMS patients (and babysit the ones who don’t rate their own room yet, though they do get a bed right away so we can leave). Our oral report goes into their (the hospital’s) electronic medical record along with that nurse’s assessment of our patient, which anyone caring for the patient can look at later- including anything important we think they should be paying attention to.

    So I suppose if anyone would be set up for semi-acceptable delayed EMS PCR delivery, it’s us.

  • Joe says:

    My agency requires all charts to be completed before you can go home.

    State DOH requires all charts to be completed within 24 hrs

    When we complete and upload, sign and lock the chart it is forwarded to our QA and the Hospital for their records

  • Apex1297 says:

    My experience with the software our department uses (Zoll) is the opposite: epcr’s can be completed much faster than a written one. Seldomly do I spend longer than ten minutes finishing my pcr at the hospital. The goal of the Zoll software is to minimize time spent on the narrative by providing a series of intuitive screens of buttons for nearly every scenario and intervention, all customizable and configurable. A reutine code 2 call rarely gets more than four lines of narrative. Furthermore, every hospital has the ability to receive the pcr printed and faxed.

    While all systems obviously don’t currently have the resources we do, it’s something the EMS community should strive for. $0.02.

  • BadgerMedic says:

    NCOEMS requires a paper PCR worksheet to be filled out and left for every patient transported. We utilize ePCRs, but the worksheet is more of a ‘down and dirty’ report.

    Recently we switched from what I’d call a ‘button-based’ ePCR (sounding similar to the Zoll system Apex1297 describes) to one that still requires somewhat of a narrative, but also utilizes button-style input. This is the third ePCR system we’ve used, and imho, the best. The ‘button-based’ software was a nightmare for QI to interpret what was going on in the call, and had to many areas that inputted information was double or triple redundant.

    This redundancy might have been partially the fault of the administrators not configuring the system appropriately, but still was not QI-friendly.

    One of the local hospitals has taken it upon themselves to create their own in-house ED hand-off report form, hopefully recording all the pertinent and important information from the EMS crew to the ED nurses. This most likely stemmed (in part) of crews either giving minimal verbal reports or not leaving the PCR worksheet with the ED staff.

    We are allocated 20 minutes from the time of pulling on the ED dock to get unloaded, register the Pt, transfer care and clean-up/restock. After that, usually you are getting asked by dispatch if you are available for another call and more times than not, dispatched to another.

    Having learned on the paper PCR, before we carried portable tablets to do ePCRs on, I find it is easer to complete the paper worksheet during the call and finish the ePCR afterwards (not to mention, the first responders are all provided these worksheets to start during their Pt care before EMS arrival.)

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Peter Canning

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