Top 3 Tips for Documenting and Securing Patient Care Data and Complying with NEMSIS 3 Requirements

Top 3 Tips for Documenting and Securing Patient Care Data and Complying with NEMSIS 3 Requirements

September 26, 2017

Since many states are now requiring EMS agencies to transition from NEMSIS 2 to NEMSIS 3 reporting standards, it’s a good time to review with your team how to properly record patient care and why it’s important.

Most EMS leaders understand that providing clear, detailed and secure patient care reports are an important part of both taking care of a patient and ensuring your agency stays compliant with government requirements.

Here are a few tips to help ensure your team is accurately completing, securing, and utilizing reports:

1.) Educate Your Team to Document Well

When reinforcing that patient care reporting should be detailed and include a narrative that paints a complete picture of both a patient’s treatment and response to treatment, take the extra time to explain why. Explain to your team that a patient care report can have an impact on many things:

  • The quality of care the patient receives
  • The decisions that other medical professionals make for the patient’s care long-term
  • Health insurance coverage
  • Staying in compliance with security and regulatory requirements

It’s important to have a holistic mindset both with your immediate treatment and when considering the patient’s long-term care. Remember, “If it wasn’t documented, it didn’t happen.”

2.) Good Data In = Trustworthy Information Out

A robust, secure ePCR platform allows your agency to consistently provide quality patient care that complies with national and state reporting and HIPAA standards. Good ePCR software can make reporting easier, quicker and more accurate. It ensures that your reports are complete before you submit them, and gives Administration a way to monitor and report upon the data. A good ePCR platform will help you quickly ascertain how many times your agency administered a certain medication or performed a procedure, for example, and help analyze patient outcomes.

3.) Dig Deep with Actionable Data

Many agencies don’t take advantage of all the practical applications and analysis that well-documented patient care can lead to. Taking time to dig deeper into what the data actually says about your agency can lead to:

  • Identifying training opportunities
  • Finding areas that may need improvement
  • Seeing new ways to work towards better patient outcomes

For example, your well-documented patient care reports will allow you to look at the cumulative numbers for how many times your team is getting IVs on the first stick or how often patients are intubated. You can watch for trends over time, to see what types of procedures are most commonly followed and if certain injuries are becoming more prevalent over time.

Furthermore, you can share this knowledge to help build strong relationships in your community. This knowledge can help local government and law enforcement reduce citizen risks. You can also ascertain the destinations your patients are being transported to most often. Knowing this can reveal opportunities to build community paramedicine programs. Sharing this data with hospitals can help improve long-term patient outcomes. It can also serve to improve response times, and reduce the chance of wasting precious time and resources because it provides insight into where to position ambulances and where the community is most at risk.


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