Journal Article

89 Clinical documentation: accurate records do not happen by accident

Pillay, Nicolas, Ali Darwish K A Karbon, Farhat, Hassan, Aloui, Mohamed, Habibi, Saber, Khaled Al Ma’aitah, Hosni Ben Brahem, Mohamed Chaker B T Khenissi, Laughton, James, Mustafa Al Dibis

2025

Overview

BackgroundElectronic Patient Care Records (e-PCR) have been the object of research since the 1980’s.1 Documentation of all the events, information shared, and medical interventions performed by pre-hospital clinicians is crucial and has been identified as important supplementation to verbal handover.2 Ambulance services play a crucial role in prehospital emergency medical care delivery. In order to provide an optimal level of centered patient care, accurate, and comprehensive documentation of the medical record is important. This project aims to improve the accuracy of the Scheduled Ambulance Service (SAS) e-PCR documentation by staff from the 1% baseline in November 2021 to 65% in October 2022, then up to 95% by July 2023.MethodsTo ensure SAS staff are continuously providing a high level of patient care, a robust and sustainable process was developed focusing on improving the accuracy of e-PCR documentation. A multi-disciplinary team used the Institute for Healthcare Improvement3 (IHI) Model of Improvement and a Cause-and-Effect Diagram revealed potential causes limiting the documentation quality and proposed viable countermeasures such as review checklist, documentation guide, Customized Improvement feedbacks and e-PCR version updating which all went through a series of Plan-Do-Study-Act (PDSA) cycles.ResultsPost-intervention data in phase 1 identified an improvement up to 80% (figure 1). From November to December 2022 data collection was on hold due to the FIFA World Cup tournament. Phase 2 data from January 2023 identified that 72% of SAS e-PCRs were completed accurately. Post-intervention data showed an improvement up to 96% by July 2023 (figure 2).ConclusionThe goal of improving the accuracy of SAS e-PCR was achieved by implementing multiple countermeasures such as revised SAS Clinical Practice Guidelines, e-PCR Documentation Guide, and implementing the top performers poster as an encouragement system to motivate the staff.Abstract 89 Figure 1Control chart of accurate scheduled ambulance service (SAS) electronic patient care records (e-PCR) documentation from November 2021 to October 2022 (UCL: upper control limit; LCL: lower control limit)[Figure omitted. See PDF]Abstract 89 Figure 2Control chart of accurate scheduled ambulance service (SA) electronic patient care records (e-PCR) documentation from January to July 2023 (UCL: upper control limit; LCL: lower control limit)[Figure omitted. See PDF]ReferencesGreenhalgh T, Potts HWW, Wong G, Bark P, Swinglehurst D. Tensions and paradoxes in electronic patient record research: a systematic literature review using the meta-narrative method. Milbank Q 2009;87:729–788. doi: 10.1111/j.1468-0009.2009.00578.xOwen C, Hemmings L, Brown T. Lost in translation: maximizing handover effectiveness between paramedics and receiving staff in the emergency department. Emerg. Med. Australas. 2009;21:102–107. doi: 10.1111/j.1742-6723.2009.01168.x.Crowl A, Sharma A, Sorge L, Sorensen T. Accelerating quality improvement within your organization: applying the model for improvement. Journal of the American Pharmacists Association 2015 Jul 1;55(4):e364–76 doi: 10.1331/JAPhA.2015.15533.Ethical Approval/IRB StatementThis is a quality Improvement project conducted during the Clinical Care Improvement Training Program, approved by the Hamad Healthcare Quality Institute, Doha, Qatar.Disclosures and AcknowledgmentsThe author would like to thank Dr. Ian Howard who assisted in reviewing and implementing of the e-PCR documentation Guide.

• Publisher: BMJ Publishing Group LTD
• Subject: Accuracy / Ambulance services / Control charts / Documentation / Emergency medical care / Health care / Quality improvement