Electronic Records

[catdsnny 0]

Is anyone aware of the usage of electronic PCRs? There appear to be state guidelines which allow for them: http://www.health.state.ny.us/nysdoh/ems/policy/08-01.htm

The EMS profession doesnt seem to be covered by the upcoming mandate to have all medical records electronic by 2015, however I'm interested to hear from other in the profession on their opinion of replacing the paper PCR with an electronic form.

[eagle5473 7]

We have been using EMSCharts for over 3 years yes it takes longer to input the reports, but the back end infor that can be pulled in seconds is well worth the time.

[ny10570 745]

FDNY has been using a paper form that is scanned for digital storage for several years. By the end of the year assuming no major problems will be transitioned to an all electronic system. I am 100% in favor of this. The possibilities this opens up to improve research, QA/QI, continuity of care, etc are worth the learning curve.

[antiquefirelt 994]

We've been using electronic reporting for about 3 years now, mandated at the state level. While I'd agree the useful information is much more accessible, I think the quality of the reports is far inferior.The reason for this is that easier is not always better. Drop down menus and pull boxes allow you to document most things, but rarely give an accurate presentation of the actual patient and incident. This is made worse by the use of "auto-narrative" generators. These auto-narratives take information from the rest of the report and magically tell the story. We determined the auto-narratives were not accurate enough for the protection of our personnel and shut-off this feature for our reports. Now, like with paper reports all must include a provider written narrative. I'd strongly encourage people to cover they asses by putting it in your own words. It's far too easy to leave things out or let the little nuances get left out, when they may be vital to your defense. After all it's not the everyday, routine stuff that will get you into hot water, but the awkward, out of the ordinary call the electronic report code writers never experienced.

That's my two cents.

[NWFDMedic 58]

I've never heard of the "auto-narrative". That sounds a bit sketchy to me. We've been using the ePCR for about 18 months now and I absolutely love them. National studies say that your average report writing time will increase slightly even after the learning curve is achieved, but it results in a much more complete report. I agree with those who posted above though, a short narrative is needed for all calls to explain the things that don't get entered on the menu or sometimes just to paint a picture that will help you remember the case in the future if the case should end up in court.

[ny10570 745]

Auto narrative takes away one of the real perks of digital records. Substantially more space for a detailed and accurate narrative.

[catdsnny 0]

I was thinking of something like a tablet PC (iPad or similar) that would have tabs across the top and you fill out (by writing with a stylus) the form. The form is then electronically transmitted to the hospital system, perhaps by wireless while in the ER. Once a day, you can dump the data down to the corp base station, or perhaps it just does it automatically when you get in range.

[antiquefirelt 994]

Another issue that's arisen in our state is the ability to amend or change reports after they've been given to the ED. Our system requires that our crews complete the report at the hospital 75-90% of the time (depends on how busy we are), then upon returning to quarters, final mileage and endig times must be entered. The report allows for additional amendments but the changes must be documents in a "reason for edit" line on every page changes are made on. This causes multiple reports with different data to be "in the system". From an admin standpoint, we're not too comfortable with the situation and it requires more extensive QA in house to ensure things are being properly documented.