Documentation of

Data Quality

 

Policy:

 

  • The complete EMS documentation associated with an EMS events service delivery and patient care shall be electronically recorded into a Electronic Health Record (EHR) within 24 hours of the completion of the EMS event.

 

Definition:

 

  • The EMS documentation of a Electronic Health Record (EHR) is based on the appropriate and complete documentation of the EMS data elements as required and defined within the South Carolina EMS Standards. Since each EMS event and/or patient scenario is unique, only the data elements relevant to that EMS event and/or patient scenario should be completed.

 

  • A complete Electronic Health Record (EHR) must contain the following information (as it relates to each EMS event and/or patient):

 

    • Service delivery and Crew information regarding the EMS Agency’s response
    • Dispatch information regarding the dispatch complaint, and EMD card number
    • Patient care provided prior to EMS arrival
    • Patient Assessment as required by each specific complaint based protocol
    • Past medical history, medications, allergies, and DNR/POST status
    • Trauma and Cardiac Arrest information if relevant to the EMS event or patient
    • All times related to the event
    • All procedures and their associated time
    • All medications administered with their associated time
    • Disposition and/or transport information
    • Communication with medical control
    • Appropriate Signatures

 

Purpose:

 

  • The purpose of this policy is to:

 

    • Promote timely and complete EMS documentation.
    • Promote quality documentation that can be used to evaluate and improve EMS service delivery, personnel performance, and patient care to the county’s citizens.
    • Promote quality documentation that will decrease EMS legal and risk management liability.
    • Provide a means for continuous evaluation to assure policy compliance.

 

Procedure:

 

  • The following procedures shall be implemented to assure policy compliance:

 

    • The EMS Electronic Health Record (EHR) shall be completed as soon as possible after the time of the patient encounter. Documentation should be completed prior to leaving the destination facility unless call demand dictates otherwise, in which case documentation must be completed prior to the end of the personnel’s shift.
    • The EHR must be completed in each agencies current EHR system and electronically submitted to Continuum within 72 hours of the EMS event or patient encounter.