Medical Report Writing Quality Improvement: Developing a Documentation Peer Review Program for the Seminole County Fire Department [open pdf - 249KB]
"Seminole County Fire Department [SCFD] utilizes a continuous quality improvement team (CQI) to review emergency medical services incident documentation. The CQI team has identified deficiencies in the accuracy and consistency in which medical reports are documented. The problem facing Seminole County Department is that its personnel generate poor medical report documentation narratives. The purpose of this research was to establish a peer review process to ensure medical documentation narratives consistently meet department established minimum documentation standards of a legally defensible report. To accomplish this purpose, this project evaluated the following: (1) what are the minimum acceptable benchmarks that must be included in every medical report narrative; (2) how could a structured narrative format be developed to assist the report writer in meeting the required minimum documentation standards; (3) what type of peer review process can be developed to improve current medical report narratives to the minimum acceptable standards using existing personnel and resources; and (4) what are the benefits of developing a peer review process in which the author and reviewer remain anonymous? Utilizing action research method, this report reviewed current report documentation practices in place under SCFD policies compared against industry-accepted standards and identified deficiencies. Next, developed a narrative guideline format checklist used to assist the report writers and the peer reviewers in writing and evaluating narratives for accuracy and consistency. An anonymous peer review process was established via the development of a policy, without incurring into expenditures or addition of administrative staff to manage the program and recommend periodic evaluation of the program to maximize its benefit."
United States. Federal Emergency Management Agency, Learning Resource Center: http://www.lrc.fema.gov/