How EMS Documentation Changed in 2020
Posted on November 4, 2020
BY FieldMed
Whether mandated by federal, state, or local authorities, EMS documentation standards change each year.
2020 saw some of the most sweeping changes to EMS reporting guidelines ever seen at the federal level with the spread of COVID-19.
The global pandemic pandemic forced first responders and agencies to quickly adapt their patient care protocols and adjust their record keeping methods -- be it paper documents or ePCR (electronic patient care reports).
While these changes are likely temporary, they are now part of daily life for first responders.
Changes to EMS Documentation in 2020
From patient treatment methods to EMS report writing, new federal EMS documentation guidelines impact all elements of first responders’ interaction with patients suspected of contracting coronavirus.
Initial Response
According to CDC guidelines, when responding to a call, first responders must log:
- A listing of EMS personnel and public safety officers involved in the response
- The level of contact those responding had with the patient
- Treatment provided
- Personal protective equipment worn
Depending on state or local guidelines, first responders may also be required to document who was also with the patient -- e.g. family members.
Should a patient require transport to a medical facility for further evaluation, first responders must log:
- The time of the transport
- The destination
- Those involved in the transport
- The vehicle’s cleaning afterward
Screenings
When first responders suspect a patient may have contracted COVID-19, CDC guidelines require screening patients for and documenting:
- Temperature
- Shortness of breath or difficulty breathing
- Fatigue
- Muscle or body aches
- Headache
- New loss of taste or smell
- Sore throat
- Congestion or runny nose
- Nausea or vomiting
- Diarrhea
This information is invaluable for prehospital care reports, as it saves doctors and other medical care staff from wasting valuable time conducting base-level evaluations for coronavirus.
Coding
As part of logging patient interactions, the CDC released new medical codes for COVID-19.
The new codes allowed EMS and other healthcare professionals to accurately document a patient's entire medical journey when suspected of having coronavirus -- from initial screening to a diagnosis.
In addition, codes were created for patients who were at high risk of catching COVID-19 because of other medical conditions, such as:
- Respiratory infections
- Acute bronchitis
- Pneumonia
- Pregnancy
Signatures
To reduce the risk of spreading COVID-19, federal health authorities relaxed patient signature requirements. Limiting the number of touchpoints between a patient and their care provider and equipment reduces the chance of spreading the virus.
EMS personnel are now allowed to obtain verbal consent and sign any patient documents -- both paper and electronic -- required in delivering care.
EMS Data Collection and the Rise of Telehealth
In some instances, medical treatment at a hospital is not quickly accessible -- think rural communities or urban centers overwhelmed by coronavirus cases. In other cases, the safest option for a patient displaying COVID-19 symptoms is to treat them in their home, limiting their exposure to others.
Telehealth medicine helped first responders meet both of these challenges, and became a popular option for COVID-19 patient treatment. The increase in remote patient monitoring and treatment meant many EMS services needed to create new forms for virtual medical care. The forms covered everything from efficiently capturing the same patient information as in-person collection to waivers allowing for remote treatment.
While no new guidelines were released for providing telehealth care to patients suspected of or diagnosed with COVID-19, the Office of Civil Rights -- which sets HIPAA regulations -- relaxed restrictions on video conferencing services.
EMS Documentation and COVID-19’s Lasting Impact
As the COVID-19 pandemic showed the EMS community, standards of care and data collection can change in an instant.
While the coronavirus is a unique circumstance, it's the job of first responders to adapt quickly to any crisis. Accurate documentation and data collection strategies are a huge part of that.