Why Complete Patient Report Forms?
Patient Report Forms (PRF) when generated become part of a patient's health history, and as such should be valued as much as any other patient record completed by other health professionals. It is a snapshot of the patient's clinical condition at a single point in time, and as such it should reflect accurately the course of a patients clinical condition while they are in YOUR care.
The PRF is evidence that patients have been treated efficiently and effectively and should also record their response to treatment. The production of accurate high quality patient records will be important for other health professionals who are involved in the care of the patient, the ambulance service who need to audit the information, the patient who will benefit from your accurate recording of their condition and you who may rely on the accuracy of your PRF when you need to defend your actions should things go wrong.
Recording Good Clinical Information through Patient Report Forms
Patient Report Forms come in a variety of formats. It is important that within an ambulance service a single consistent PRF format should be adopted - and it should be versatile enough to cater for the requirements of all users, and particularly be user friendly, practical, encourage completion in as comprehensive a manner as possible - and therefore be as simple to complete as possible. Inevitably they will form the basis of a minimum data set required for clinical audit purposes, and to monitor quality standards - whether clinical interventions or response times. However, they should also incorporate sufficient flexibility to allow recording of information not catered for within a tick box format - as every patient is unique and requires the recording of unique information that may well have an influence on clinical management. End point users of PRFs must have a significant input into their design, and proposed formats must be thoroughly piloted before universal introduction.
The core function of the PRF must never be forgotten, which is the recording of information by an ambulance health professional in connection with the care of a patient. It should allow another medical professional to reconstruct your relationship with the patient while they were in your care.
Ideally they should include:
History - relevant to the condition, including any answers to direct questions.
Examination of the patient - any important findings, both positive and negative, and details of any objective measurements, such as blood pressure.
Diagnosis - in dear, readily understood terms.
Information - what YOU have told the patient, including any details Df the risks and benefits of particular treatments, and recording of allergy Dr sensitivities to treatments. E.g. Aspirin sensitivity.
Consent - is normally implied but requires where possible the patients agreement to treatment, and where a patient declines an appropriately proffered treatment or intervention this must be documented.
Treatment - detail the type and dosage of drugs, the total amount prescribed and any other treatment undertaken - including the time at which it was given/commenced.
Progress - how the patient responds to treatment, whether this is positive or negative.
It is not only the content that is important, but the way that the information is recorded. In some PRF formats, there may be little scope for variation or expansion on the information that needs to be recorded - e.g. Tick Box PRFs. However, whatever format is used some basic principles apply:
Clear - identify thee patient clearly, with their name, date of birth and address. Write legibly in black ink, and ensure there is no room for ambiguity in tile interpretation of the record You make. Sign each entry and where necessary print your name or record your unique registration number. Ensure that the PRF is dated, including the year, and any key times noted by the 24 hour clock. Be careful when using abbreviations.
Objective - opinions should be based on the facts You have recorded. Remember that patients or their relatives or even legal advisers may ultimately have access to the PRF.
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Contemporary - complete the PRF at the time of the event - a copy should be available on handing over care of the patient at hospital.
First-hand - if information has been given to You by anyone but the patient, record that person's name and position. For example, it may be a relative, friend, translator, Or the Garda.
Tamper-proof - any attempt to amend records should be immediately apparent. So, for example, PRFs should always be written in black pen, not pencil.
Original - implied by the last point, PRFs should not be altered or amended. If you make a mistake, insert an additional note as a correction. Make it dear that this is a new note, not an attempt to tamper with the PRF. PRFs should only be amended if the original information was inaccurate, misleading or incomplete.
Complaints and Claims
Accurately completed Patient Report Forms are essential in responding to complaints and claims. They provide an objective record of the treatment of a patient. If the ambulance service faces a claim for negligence, accurately recorded information on a PRF will be an essential part of the defence of that claim. Your care of the patient will be judged by the quality of the information you have recorded. Many clinical negligence claims are indefensible because there are problems with tile medical records, whether they are inaccurate, illegible, inadequate or simply missing. You may have done nothing wrong, but unless the PRF can prove this, it can be difficult to defend a claim - and consequently maybe difficult to defend your reputation. Courts have a tendency to believe the memory of a patient, for whom it was a once-in-a-lifetime experience, rather than the memory of a health professional who maybe recalling many years later one of many similar situations.
Auditing and Corporate Governance
As well as enabling high quality care for individual patients, accurately completing PRFs is increasingly valuable in improving standards of patient care. Auditing PRFs is an important part of the clinical governance process, and as mentioned earlier, PRFs should be designed in such a way that facilitates this. Most ambulance services have standard templates for PRFs, but there are probably as many variations as there are services - and the universal PRF remains elusive.
Who can have access to the Patient Report Form?
A wealth of legislation covers access to medical records. The ambulance service management will normally deal with requests for access to the information contained in PRFs - it is simply prudent to remember that inappropriate subjective comments made in the heat of the moment could well come back to haunt you at a later date, when your PRF record is accessed by the patient, their relatives or their solicitors. The subjective comment that a patient is "play acting" or "playing up" when they subsequently die from a condition that was not immediate ly obvious does not refiect well on your professional objectivity.
In disclosing information to third parties, always be mindful of the patient's right of confidentiality, and remember that your duty of confidentiality does not end when your patient dies.
In Summary
Ambulance Professionals have a duty to complete Patient Report Forms accurately - it is a measure of good clinical practice. It may also provide evidence in responding to complaints and claims, and it is likely to be an essential tool for clinical audit and supporting corporate governance.
Dr Richard Lewis
OBStJ., MBChB, MRCGP, DiplMC RCS(Ed)
Dr Lewis is a GP and a former Medical Director to an Ambulance NHS Trust. He has a Post Graduate Diploma in Immediate Medical Care and is a Founder Member of the Faculty of Prehospital Care at the Royal College of Surgeons of Edinburgh.
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