Documenting Patient Interaction: Emergency Medical Services Report Reader Expectations and Improvements for Providers.

Abstract

Introduction: Patient care reports contain critical elements related to interventions rendered and medical decision-making. Yet, little consensus exists around reader expectations, leaving emergency medical services (EMS) providers unaware of critical content.

Objectives: This 2-phase study aimed to answer the questions "What do EMS providers know about report readers?" and "What do report readers expect from reports?" through surveys and interviews. In doing so, this study gauged EMS providers' audience awareness of report readership and determined what readers expected from reports.

Methods: A prospective survey was conducted with 57 EMS providers to gauge their level of audience awareness or how often they thought of specific report reader groups when writing reports. Interviews were conducted with 14 report readers following retrospective think-aloud protocol, where participants verbalized their questions, comments, and concerns about reports while reading.

Results: Surveys indicate participants lacked a full, accurate sense of audience awareness. When writing reports, they thought of audiences, such as patients, who do not regularly read reports, while reporting not thinking of actual report readers-such as billing specialists-often or at all. Interview analysis indicated that report readers looked for 21 elements in high-quality, effective report narratives.

Conclusions: These data formalize and reinforce what a high-quality narrative should include, with "high-quality" meaning the narrative allows readers to do their jobs without follow-up or an amendment needed to the report.