In the UK up to 30% of people who call for an emergency ambulance (999 calls) are, for various reasons, not conveyed to hospital,1 2 a situation similar to that found elsewhere in the world. In the USA, considerable work has been done to assess the safety of non-conveyance,3 4 prompted by concerns over the clinical and litigation risk of this practice.4^–9 Safety concerns have been consistently raised by these studies.

Research suggests that the completion of clinical documentation is generally associated with good quality care, although benefits may be indirect.10 11 Davidson et al,12 writing on the records kept by doctors in the context of emergency care in the USA, identified several purposes for clinical documentation. Two of these are highly relevant to this study: the recording of medical care for communication among providers; and legal defence from allegations of negligence.

Despite the acknowledged importance of clinical documentation, earlier studies of documentation in emergency medical services13 14 have found worryingly high levels of non-completion, particularly in cases where patients are left at the scene of their emergency, rather than being taken to hospital. Several studies in the USA on deficiencies in record keeping found them to be linked to whether online medical control was used to make decisions,9 the level of training undertaken by ambulance staff,15 and whether or not patients appeared to have any injury or illness.16

A previous study in one ambulance service trust14 suggested that clinical documentation may not be completed in up to 80% of non-conveyed cases. This worrying finding provided the background for a qualitative study in the same trust.

The aim of the study which is described in this paper was to describe the views and attitudes of paramedics towards completion of clinical records, particularly in relation to patients who were not conveyed to hospital, on:

• whether clinical records should always be completed

• the value of clinical records

• whether the records reflect the clinical care given

• what may prevent records from being completed

• what may encourage crews to complete records.

Standard practice in the study trust was for all patients to be taken to a hospital accident and emergency unit once an ambulance had attended a call, unless they refused to travel and were regarded as competent to make the decision to refuse. Policy required that crews complete a Patient Clinical Record (PCR), an A3 form noting operational, biographical and clinical details, for each patient. The form was self-copying, with the top copy being kept by the ambulance service and the second copy going to the staff in the accident and emergency unit, or, in the case of non-conveyed patients, to be passed to the general practitioner (GP) by the patient.

METHODS

The study received ethical approval from the local research ethics committee. Three focus group interviews were carried out with paramedics who were attending in-service training days. The size of the groups ranged from 6–10, with a total of 25 people taking part. Each group was led by a facilitator using a pre-prepared topic guide, with an observer sitting in. Interviews were tape recorded and transcribed, then analysed using the N6 computer program for qualitative analysis, which supports coding of text and the structured grouping of codes into themes. A coding frame was developed from the original research objectives and from themes emerging from the interview transcripts. A group analysis session of four researchers was held to discuss and check the coding frame and initial analysis.

Where verbatim quotes are given below, each speaker has been given a unique identifier. The letter code identifies which group the quotation is taken from, and the number is used to distinguish between speakers in each group. “I” represents the interviewer. Except where noted, quotations have been selected to reflect consensus or the majority opinion among the group.

RESULTS

Crews’ views on whether clinical documentation should always be completed for non-conveyed patients

Although participants in all the focus groups started off by saying quite clearly that PCRs should be completed in all cases, it soon became clear that there were cases where this was not happening.

These cases fell into three types. The first were those where the patient refused to cooperate and give information. They might have been people who slammed the door in the face of the ambulance crew, or people who appeared to be intoxicated and left the scene before they could be questioned. This last category made up a significant portion of the crews’ work:

A5: I’ve gotta be honest, I would say that Monday to, say, a Wednesday, you would complete one of them (PCR). Thursday to Saturday forget it ….I would say 10% of them are, the rest of them are all drunks, assaults, they are not going to give you the information required on that.

The second category of patients comprised those involved in road traffic collisions. Here, crews believed that the PCRs should be completed, but sometimes ran up against practical difficulties, simply because of the numbers of people involved, and the fact that people can wander off without being assessed.

The third category of patients for whom PCRs were not always completed was made up of older people who had fallen. Some of the crew members acknowledged that in cases where they felt that there was no injury, based on their own judgement and the mechanisms involved, the PCR would not necessarily be completed. However, there was disagreement between different crew members on this subject; some urged caution, because injuries are not always easily spotted.

Crews’ views on the value of clinical documentation

The initial response within all the focus groups to questions about the value of clinical documentation was cynically humorous:

I: What do you see as the value of the (PCR)?

A4: To the patient?

I: To anybody.

A1: None.

A5: To nursing staff – none.

A3: To clinical ops [audit department] – everything.

[laughter all round]

A3: It’s just an audit. It’s statistics.

Another group gave the two main uses to which forms were put as “scanning” and “shredding”. On further discussion, however, it became clear the crews have in fact developed quite a wide ranging perception of the form’s value. Some aspects of this were:

• to “cover their backs” if something were to go wrong

• as an aide-memoire, ensuring that crews carry out all the necessary clinical observations

• collecting information for managers, to allow them to analyse what is going on in the service

• to provide continuity of care, though this was mostly discussed in relation to patients who were conveyed to accident and emergency, and the PCR’s clinical value in relation to non-conveyance cases was perceived as minimal

• to act as a reminder of what happened, if, for example, a paramedic is called on to act as a witness in court following a stabbing

• if ever an ambulance was caught speeding, to provide evidence that they were legitimately hurrying to a call.

The biggest part of the discussion about the PCR in each focus group was to do with “covering their backs”. In some cases, they linked this explicitly to the role of the PCR as a clinical record:

A1: The only proof that we paid attention to the patient in the right way is what we write on there.

In other cases, the comments seemed to be part of a bigger picture of unease and defensiveness about the crews’ role:

B3: If it’s not on the form, it hasn’t happened…

B2: If it’s happened, it’ll be down there. If it hasn’t happened, it’s not on there.

B3: And if it hasn’t, then why. Covering your arse, basically. I think on this job you’re trying to cover your arse most of the time.

B8: Spend most of your time covering your arse.

Crews’ feelings about the PCR were complex and ambivalent. As one crew member pointed out, if the PCR is mainly valuable in extreme situations, then:

C3: They’re a waste of time most of the time.

Crews’ views on whether the paperwork reflects the clinical care given

Broadly speaking, crews did seem to have faith that the paperwork they completed reflected the clinical care given. Clinical care seemed to be interpreted to include care administered—drugs, treatments and procedures—and associated clinical observations. Clinical care was seen as distinct from the “social care” aspects of their job, including putting people back into bed, and making referrals to other professionals, which would not necessarily have been recorded in the same way. Some crew members talked about the clinical observations as being a part of a bigger process of care and advice giving, and emphasised the importance of recording all of it on the PCR:

A1: At least it shows that you had a look at what is going on, so when you give them advice as to why they should go [to hospital], the advice is based on the obs that you have done. Your blood pressure is low, your heart is racing, or whatever.

Crews’ views on what may prevent paperwork from being completed or encourage them to complete it

Crews were very willing to talk about what might discourage them from filling in forms, but talked little about what would encourage them to complete them. A number of factors operated alone or in combination to prevent paperwork from being completed. The first of these was the practical difficulty of getting information from uncooperative patients. The second was the sense that something was a “non-case”—one which did not warrant a written report, since the crew felt they did not use any of their clinical skills in dealing with it, as illustrated by the cases of some older people who had fallen, of which the following is an extreme example:

C3: We’ve got a regular who slips off the chair all the time. Leather chair, she always slips off. It’s just a case of picking her up, going, boomf! “Are you comfortable? Great”. There isn’t anything wrong with her.

The third factor inhibiting the completion of the PCRs can be summarised as a prevailing work culture which views the forms as a management tool for berating staff. If the forms were only partially completed, crew members would be expected to explain why the information was missing. By not completing a form at all, the crew was able to avoid the risk of any of this happening. However, they were keen to emphasise that this happens only if the situation is one of those “non-cases” described above:

C1: (chuckling) You’re safer not putting the form in.

C4: Cause you’re anonymous. Once you put the pen to paper you are open for criticism, in that sense. Obviously, if you give treatment you put it in every time.

This situation could happen because nobody was cross-referencing between the log of calls and the PCRs, and checking where missing PCRs might be. So the fourth factor allowing non-completion of PCRs was an inadequate system for auditing completion.

The fifth factor was that, at times, the crews did not wish to make the effort. On its own, this would not stop crew members from completing forms, but in combination with other factors, it could be enough to make the difference:

C10: There is a point about recording and documenting your findings. But a lot of people think, oh yeah, 4 o’clock in the morning, can I really be bothered?

DISCUSSION

Interpretation

Crews were very conscious of the need to “cover their backs” in non-conveyance cases, but were not always filling in the documentation which would enable them to do this. This is a worrying situation, since it represents a clear clinical risk. Also worrying is the fact that crew members did not, on the whole, seem to be concerned about the situation.

It is possible that two factors may have been at work. Firstly, it appeared that crews, while being aware of risk as an aspect of their work, felt as if there was nothing they could do about it. In some cases crews gave the impression of working with “fingers crossed” that there would be no come-back, but still would not make a record which might protect them in the future.

Secondly, many (though not all) of the crew members seem not to be acknowledging the risks associated with particular calls, especially older people who fell and were not conveyed. Assumptions were made that no record of any formal assessment was necessary for apparently uninjured fallers. The fact that crew members did not acknowledge the risk in these circumstances may be part of a wider perception of these calls as “non-jobs”—not one of the tasks which the crews were employed and trained to do.

In order to find ways of increasing the completion rate of paperwork, the ambulance trust would need to take account of some ambivalent feelings on the part of crews about the value of the paperwork and implement systems for monitoring its completion. Crews appeared not to believe that the PCRs are actually used and useful. As far as crews could see, the forms were not being used effectively either for monitoring performance or as a service planning tool. It is likely that crews would be encouraged to complete paperwork for non-conveyed patients if they could see that the PCRs were actually being put to use, as part of the ongoing care for the patient. Current developments in integrating care systems for older people who fall may provide scope for this, with ambulance crews potentially sending on PCRs to community based falls teams as an intervention.17 Similarly, rates of completion would be likely to be boosted if effective monitoring systems were in place—for example, supervisors examining reports that tie a dispatch-derived call number to patient clinical records to identify gaps. Moves taking place at national level towards the introduction of electronic patient records should make this more readily achievable.18

Limitations

The data were gathered in just one ambulance service trust. The 25 paramedics who took part in the study were only a small proportion of the total number employed by the trust.

Conclusions

This study highlighted a worrying situation in this trust, whereby crew members appeared to be aware of risk in relation to clinical documentation, yet reluctant to take action to try to reduce it. There are lessons for the trust, which needs to tackle this area of clinical risk, but in a way that will engage its clinical operational staff. Staff need to feel confidence in the system, and that they are accountable for their work within a structure that offers appropriate support for the decisions they make. We know from other studies that concerns about high rates of non-completion of clinical documentation are by no means confined to this trust; the issues raised in this study are worth considering in other contexts.

Ambulance services in the UK are beginning to go through a culture change which places greater emphasis on records as an integral part of patient care, and on paramedics as autonomous practitioners. As alternative responses by ambulance services are implemented,19 requiring ambulance crews to make triage decisions concerning the onward care of 999 patients, detailed records of the assessment and management of patients who are not taken to hospital will become increasingly important. The quality and safety of care provided can only be ensured if appropriate clinical documentation is completed for all 999 patients attended.