The Five Dangers of Poor Documentation in Community Paramedicine

Documentation may be boring, but it’s a critical element of community paramedicine. Good documentation leads to optimal reimbursement, better communication, and legal protection. However, poor documentation for community paramedicine often has consequences. 

Poor documentation for mobile integrated healthcare-community paramedicine (MIH-CP) will cause suboptimal patient care, strained communication, and a potentially shaky reputation. In addition, lousy documentation reduces the potential for accurate reimbursement, limits data accuracy, and alienates partners.

This article will discuss the downsides of lackluster documentation, and it will also go over some of the ways to strengthen data collection and documentation for community paramedicine. 

Consequences of Documentation Mistakes in Mobile Integrated Health-Community Paramedicine

Community paramedicine records fall under pre-hospital documentation. MIH-CP documentation involves the gathering and recording of patient information related to the providers’ service, including vital signs, general impressions, environmental changes, treatments rendered, allergies, and much more. 

This article will highlight some of the dangers of poor documentation while also underscoring the benefits of good documentation. At the end of this article, we’ll discuss tips for improving community paramedicine record-keeping.

Here are some dangers of inadequate MIH-CP documentation: 

  • Sub-optimal patient care 
  • Strained communication within the team 
  • Shaky reputation and partnerships 
  • Reduced reimbursement potential 
  • Limited data accuracy 

Let’s take a close look at each of these categories. 

Bad MIH-CP Charting Leads to Sub-optimal Patient Care 

Patient care is the bedrock of a community paramedic program. Like any service, whether it’s a restaurant or a car mechanic, the customers will be satisfied if the product is good, and the community will be better for it. 

This is never truer than in healthcare. Although at the same time, we’d all like to believe that healthcare is functioning at an optimal level in all areas of the country and all agencies, the fact is that some regions excel. In contrast, others struggle to maintain a vital service. 

Good documentation leads to better patient care, and bad documentation leads to errors, wasted time, and lost money. In addition, if documentation is disjointed, it makes it harder for crews to keep track of where a patient is in their care and where they need to improve their services. 

The patient documentation is a log—a map. If the map is inaccurate, the crew will wander off course, and care will flounder.

Poor Internal Communication

There needs to be more documentation to ensure clarity within an MIH-CP program. For example, two providers visit a patient on different days of the week. If there is insufficient documentation, there’s a chance one provider will duplicate services or ignore services they assume were already performed. 

Community paramedicine is all about strong communication. Community paramedicine almost always necessitates partnerships with external groups, such as the hospital or a physician’s office. These groups are disconnected from the EMS company operating the community paramedic program. If an MIH-CP program can’t communicate internally, how will it be able to communicate externally? 

Good internal communication is the engine that gets a community paramedicine program moving, but external communication and partnerships are the wings that take it off the ground. 

Bad Community Paramedicine Documentation Causes Shaky Reputations and Weak Partnerships

Building strong partnerships is paramount to a thriving community paramedic program. However, for long-term success, community paramedicine programs realize that the needs of a community will ebb and flow and that their program will need to adjust as well.

This means that sometimes they will need to reach out to older populations, sometimes to younger populations, and sometimes they will need to sit back and listen to what the community is saying – they may be required in unexpected ways.

However, this comes down to building and maintaining external partnerships. This can be a little difficult in the beginning. Some EMS companies are large and familiar with talking with various facilities and forming partnerships. However, other groups have operated relatively unchanged, only interacting with the usual partners, such as the hospital and the fire department – these agencies will need to push themselves to expand. 

Good documentation ensures they will be able to connect with partners in a meaningful way. If documentation is inaccurate, disorganized, or disintegrated, it will be difficult for two teams to connect. Not only that, but it could cause any budding partnership to be marred. A tainted reputation is hard to restore.

Poor MIH-CP Documentation Leads to Reduced Reimbursement Potential 

In EMS and mobile integrated healthcare, payment and reimbursement have become clouded with stigmas and expectations. Some areas talk about and plan for reimbursement openly, while other areas still need clarification when thinking about money and avoid planning as they should. 

If mobile integrated healthcare is to move forward, more people need to advocate for a robust reimbursement model. But, again, good documentation helps pave the way for better reimbursement.

If crucial elements of patient care are ignored and undocumented, there is no way to be accurately reimbursed for those services. If this is a chronic problem, the organization will lose money and see its growth potential stifled. 

Along with advocating for a better reimbursement model, MIH-CP programs need to ensure they aren’t leaking money from the shadows – good documentation is an area that often goes unnoticed. 

There’s another connection between good documentation and reimbursement: time. Documentation that is free of error and does not require frequent addendums will be more likely to pass through billing successfully, thus leading to a steadier cash flow. Conversely, if documentation is sloppy, there will be a bottleneck that limits the potential for steady reimbursement. 

If you’re curious, read this article on 4 ways for MIH-CP to generate revenue.  

Limited Data Accuracy from Poor MIH-CP Documentation 

Data collection is different from the documentation. Documentation is the physical act of recording the patient encounter, ensuring that the encounter was accurately described. However, data collection is different. Data collection now looks at the documentation and pulls recurring data from the report. 

This data could be demographics or a specific issue. For example, the number of ER visits by each patient in the program is a particular data point that can be collected and analyzed. Why is good data important? 

Good documentation leads to good data, which leads to good partnerships and a strong program. By practicing accurate documentation in the field, you can perform a more effective data analysis in the office. This data can then be used to explain and attract more partners.

For example, if you reach out to the local senior center, they will ask why they should be involved in your program. When you say that the patient enrolled in your program have shown a consistent decline in hospitalization, they will see that supporting your program directly supports their cause. 

Yes, you could tell them your goal is to help their constituents; however, numbers talk. If you have data to support your actions, you’re more likely to attract and retain partners. Not to mention more funding for your program.

We’ve talked about some of the dangers of poor documentation for integrated healthcare, but now let’s talk about ways you can strengthen your documentation program. 

How to Improve Documentation for Mobile Integrated Healthcare 

If this article convinced you of the dangers of poor documentation, you might be asking: how do I foster good documentation for my community paramedic program? How do I know where we’ve gone off track? Use the checklist below to perform a self-assessment.

How to strengthen documentation for community paramedicine: 

  • Talk to the people. Talk to the people who are performing documentation. Ask them if the information they record is accurate. Do they feel that their partners do an adequate job of documentation? Do they have time to perform good documentation? Are they rushed? Think about training. The providers should have the training and experience to systematically and accurately document their patient encounters and be aware of the legal ramifications of inaccurate documentation
  • Look at the product. Look at the documentation charts. Many companies will perform internal audits. This can be done without infringing on privacy rights. When people know peers may review their work, they’re more likely to put in the effort for good documentation. However, they will also see examples of what works well and what doesn’t. 
  • Look at the platform and tools. Does the software you’re using allow for good documentation? Sometimes, the software can provide a real hang-up. If the crews think the software tools are holding them up, they will be less likely to spend time on good documentation (and more likely to take shortcuts). 

Time for our conclusion.

Conclusion: Good Tools for Strong MIH-CP Documentation

Good documentation can open doors for your community paramedic program. Insufficient documentation will slam these doors shut. But on the other hand, good documentation will lead to better revenue flow, stronger partnerships, and more efficient patient care. 

Mobile Integrated Healthcare documentation software is a crucial component. Just like you can’t mow your lawn with a butter knife, you can’t perform good documentation with subpar software tools. Julota provides a platform that allows providers to seamlessly document their MIH-CP patient encounters. In addition, Julota’s platform is secure, cloud-based, and interoperable. 

Contact Julota to discover how they can take your MIH-CP documentation and data collection to the next level. A representative would be happy to listen to your needs, answer any questions, and provide a demonstration.