"Covering our backs": ambulance crews' attitudes towards clinical documentation when emergency (999) patients are not conveyed to hospital

Emergency Medicine Journal : EMJ
Alison PorterMalcolm Woollard

Abstract

Up to 30% of people who call for an emergency ambulance are, for various reasons, not conveyed to hospital. Across the UK, the majority of ambulance services have policies and procedures requiring ambulance crews to complete clinical documentation for these patients, as they do for patients who travel to hospital. However, studies have suggested that documentation does not get completed for a large proportion of non-conveyed patients. A qualitative study in one large ambulance service trust used focus groups to explore crew members' attitudes towards clinical documentation and non-conveyed patients. Considerable ambiguity was found: crews were aware of the need to "cover their backs" by completing clinical records, but at the same time expressed doubts about the value of this documentation. There appeared to be two main circumstances in which records were not completed. Firstly, there were the cases where crews may have been unable to obtain necessary information from patients who were intoxicated or otherwise uncooperative. Secondly, there were cases where the crews may not have recognised their encounter with a patient as having a clinical dimension, such as older people who had fallen but were apparently uninjured. These cir...Continue Reading

Associated Clinical Trials

Citations

Dec 5, 2014·Journal of Health Services Research & Policy·Rachel O'HaraJane Shewan
Oct 13, 2009·European Journal of Emergency Medicine : Official Journal of the European Society for Emergency Medicine·Lucy PickardAneel Bhangu
Jan 25, 2018·Acta Anaesthesiologica Scandinavica·S PekanojaS Elo

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