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Standard operating procedures as a tool to improve medical documentation in preclinical emergency medicine
  1. Roland C E Francis1,
  2. Willi Schmidbauer2,
  3. Claudia D Spies1,
  4. Marc Sörensen1,
  5. Florian Bubser1,
  6. Thoralf Kerner1,3
  1. 1Charité—Universitätsmedizin Berlin, Klinik für Anästhesiologie m.S. operative Intensivmedizin, Campus Virchow-Klinikum und Campus Charité Mitte, Berlin, Germany
  2. 2Bundeswehrkrankenhaus Berlin, Abteilung für Notfallmedizin und Rettungsdienst, Berlin, Germany
  3. 3Asklepios Klinik Harburg, Abteilung für Anästhesiologie und operative Intensivmedizin, Hamburg, Germany
  1. Correspondence to Dr med Roland C E Francis, Klinik für Anästhesiologie mS operative Intensivmedizin, Charité—Universitätsmedizin Berlin, Augustenburger Platz 1, Berlin 13353, Germany; roland.francis{at}charite.de

Abstract

Aim To evaluate the effect of standard operating procedures (SOPs) to improve the completion of patient care documentation items on patient care reports (PCRs) in a physician-staffed, 4500-calls-per-year preclinical ground emergency medical service (EMS) base.

Methods Two series of PCRs were analysed before (n=505) and after (n=520) the introduction of SOPs. PCR forms were analysed for the rate of completion of documentation comparing prompted data in check boxes and non-prompted data written in blank spaces at the discretion of the emergency physician. The χ2 test for independence was used to assess the effect of SOPs and prompting on data completion rate.

Results SOPs improved the documentation rate of numerous prompted and non-prompted items, independent of whether these items had a high (eg, Glasgow Coma Score: 91.5% vs 95.7%) or a low documentation rate during the pre-SOP period (eg, allergies: 6.2% vs 18.7%). Prompted items were more frequently documented than non-prompted items, both before and after the introduction of SOPs. Lowest rates were found among non-prompted items (eg, ‘last meal’ 3.6%).

Conclusions In this EMS base, developing SOPs is an effective tool to improve the quality of PCRs and the rate of completion of documentation items. Check boxes on PCR forms seem to have an important impact as they prompt the initial assessment, treatment and documentation of the actions taken during an EMS call. Consequently, SOPs and check boxes may serve to improve the transition of important information to emergency department staff, and thus contribute to improved patient care.

  • Standard operating procedure
  • quality management
  • emergency medicine
  • documentation
  • patient care reports
  • emergency care systems
  • management, quality assurance
  • nursing, prehospital
  • prehospital care, doctors in PHC
  • psychology, staff support
  • EMS
  • emergency medical service
  • PCR
  • patient care report
  • SOP
  • standard operating procedure
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Footnotes

  • Competing interests None.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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