Summary
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.
Keywords
Documentation - quality improvement - emergency medical technicians - universities
- emergency medical services - electronic health records
