Impact of implementing an EMR on physical exam documentation by ambulance personnel
31 March 2012
accepted: 20 June 2012
16 December 2017 (online)
Objective: Georgetown University has a student run Emergency Medical Services (EMS) organization with over 100 emergency medical technicians (EMTs). We set out to determine whether implementing an electronic patient care report (ePCR) system was associated with improved physical exam documentation.
Methods: This study evaluated documentation of the physical exam on prehospital patient care reports (PCRs). An ePCR system was implemented. ePCR documentation was compared to that of the previously used paper PCRs. This study looked retrospectively at 154 PCRs. 77 were hand written PCRs from before the electronic system. The PCRs involved chief complaints that were primarily respiratory, neurologic, or both. 77 ePCRs of matching chief complaint categories were used for comparison. Each chart was reviewed for completion of certain physical exam findings. The mean percentage of documented components from the ePCRs was compared to that of the hand written PCRs. The null hypothesis was that the absolute increase in the mean was not more than 20 percent. The two exclusion criteria were PCRs completed by study investigators after the design of the project and partially or completely missing PCRs.
Results: The absolute increase in mean physical exam component documentation was 36% (95% CI = 29–43%). A weighted kappa of 0.894 showed very good agreement between chart reviewers.
Conclusions: This study rejected the null hypothesis that the ePCR system was associated with a mean increase of no more than 20%. It observed increase in physical exam documentation. Limitations of this study included the inability to determine whether documentation of physical exam findings reflected performance of the physical exam, and what components of the ePCR system bundle were responsible for the increase in physical exam component documentation.
- 1 National Collegiate EMS Foundation [Internet].. West Sand Lake New York: National Collegiate Emergency Medical Services Foundation; c2000–2012 [cited 2012 March 30]. Available from: http://www.ncemsf.org.
- 2 Joyce SM, Dutkowski KL, Hynes T. Efficacy of an ems quality improvement program in improving documentation and performance. Prehosp Emerg Care 1997; 1 (03) 140-144.
- 3 Staff T, Søvik S. A retrospective quality assessment of pre-hospital emergency medical documentation in motor vehicle accidents in south-eastern Norway. Scand J Trauma Resusc Emerg Med 2011; 19: 20.
- 4 Laudermilch DJ, Schiff MA, Nathens AB, Rosengart MR. Lack of emergency medical services documentation is associated with poor patient outcomes: a validation of audit filters for prehospital trauma care. J Am Coll Surg 2010; 210 (02) 220-227.
- 5 Moss RL. Vital signs records omissions on prehospital patient encounter forms. Prehosp Disaster Med 1993; 8 (01) 21-27.
- 6 Deckelbaum DL. et al. Electronic medical records and mortality in trauma patients. J Trauma 2009; 67 (03) 634-636.
- 7 O’Connor RE, Megargel RE. The effect of a quality improvement feedback loop on paramedic skills, charting, and behavior. Prehosp Disaster Med 1994; 9 (01) 35-38.
- 8 Kiefer VF, Schwartz RJ, Jacobs LM. The effect of quality assurance on flight nurse documentation. Air Med J 1993; 1 1–2 11-14.
- 9 Bergrath S. et al. Is paper-based documentation in an emergency medical service adequate for retrospective scientific analysis? An evaluation of a physician-run service. Emerg Med J 2011; 28: 320-324.
- 10 Francis RC. et al. Standard operating procedures as a tool to improve medical documentation in preclinical emergency medicine. Emerg Med J 2010; 27 (05) 350-354.
- 11 Kuisma M. et al. Effect of introduction of electronic patient reporting on the duration of ambulance calls. Am J Emerg Med 2009; 27 (08) 948-955.
- 12 Faul F, Erdfelder E, Lang AG, Buchner A. G*Power3: a flexible statistical power analysis program for the social, behavioral, and biomedical sciences. Behav Res Methods 2007; 39 (02) 175-191.
- 13 Ash JS, Berg M, Coiera E. Some unintended consequences of information technology in health care: the nature of patient care information system-related errors. J Am Med Inform Assoc 2004; 11 (02) 104-112.
- 14 Ash JS. et al. Some unintended consequences of clinical decision support systems. AMIA Annu Symp Proc 2007: 26-30.
- 15 Landman AB. et al. Prehospital electronic patient care report systems: early experiences from emergency medical services agency leaders. PLoS ONE 2012; 7 (03) e32692.