Development of a checklist for assessing completion of patient report forms by paramedics in South Africa

Abstract

Introduction The completion of medical records is of vital importance and is seen as an integral part of patient care. One of its key functions is to facilitate continuity of care when the responsibility for medical care of a patient is transferred from one healthcare practitioner to another. In the pre-hospital environment, paramedics use patient report forms (PRFs) to record the details of the patient’s condition and the treatment provided to the patient. Poor documentation of medical care by paramedics on PRFs has been shown to increase mortality among patients treated by paramedics. There are several other potential consequences of poorly completed medical documentation which place the patient at risk, including a longer hospital stay, increased medical costs, duplication of tests and poor communication between multidisciplinary teams. Current advice for South African paramedics on how to complete a PRF and the information that is required to be recorded on a PRF is limited. Aim of the study The aim of this study was to develop a checklist to assess the quality of vital patient information recorded, and the documentation of patient care provided, by South African paramedics in the pre-hospital environment. Objectives The objectives to achieve this were: 1. to retrieve and list data elements for the completion of a PRF by conducting a scoping review; 2. to refine the information and seek expert consensus by using a Delphi survey to determine which data elements satisfied the criteria for assessment on the proposed checklist; and 3. to design and develop a checklist based on the data elements agreed upon by experts in the Delphi survey. Methods A scoping review was conducted to identify what information is available, useful and significant for the completion of a PRF. Expert consensus on what specific important information is required for the completion of a PRF (and therefore needs to be part of the proposed checklist) by paramedics in South Africa was obtained through a threeround Delphi survey. Results Based on the results of the scoping review, a three-round Delphi survey was used to develop the list of elements for a proposed checklist. This checklist can be used to assess and audit the recording of vital patient information and the documentation of patient care provided by paramedics. Conclusion Poor medical documentation has multiple direct and indirect implications for patient care. It has been shown that South African paramedics omit vital information when completing PRFs. A checklist was developed to be used in quality assurance programmes to assess the completion of PRFs. Further research regarding the effectiveness of the checklist is required.