Purpose Statement

The AI-Powered ePCR Documentation feature streamlines the creation of Patient Care Reports by allowing EMS providers to record patient care details verbally through medical-grade speech transcription combined with AI processing. This technology automatically populates NEMSIS ePCR fields, significantly reducing documentation time while maintaining accuracy and compliance standards for emergency medical services.

Background Information

This innovative documentation system combines advanced speech recognition technology optimized for medical terminology with artificial intelligence field mapping to transform verbal patient reports into structured ePCR data. The system supports up to 100 different NEMSIS data fields and processes various types of clinical information including vital signs, medications administered, physical assessments, patient history, treatments provided, and transport information.

The feature operates on a "Human-in-the-Loop" principle, ensuring that all AI suggestions require provider review and approval. This maintains the provider's full responsibility for documentation accuracy while leveraging AI assistance to reduce manual data entry and improve efficiency in patient care documentation workflows.

Required Permissions

Based on the system structure, users need the following permissions to utilize AI-Powered ePCR Documentation:

Required for Basic AI ePCR Access:

• ePCR > General > EMS Care Report access
• ePCR > General > Create and Edit EMS Care Reports

Required for Full Documentation Workflow:

• ePCR > General > View and Edit Patient Care Reports

Note: All AI suggestions must be reviewed and approved by licensed EMS providers. The system assists but does not replace proper medical documentation responsibilities.

Best Practices

Do's

• Speak clearly and provide complete information during verbal reports
• Think of your recording as a comprehensive patient handoff report
• Review all AI suggestions thoroughly before accepting them
• Use the feedback system to report issues and suggest improvements
• Include all relevant clinical details in your initial verbal report to minimize manual entry
• Verify accuracy of all documentation before finalizing patient care reports

Don'ts

• Don't rely solely on AI suggestions without thorough review and verification
• Don't skip the review process even when suggestions appear accurate
• Don't forget that multiple recording sessions will append to existing narratives
• Don't assume all medical terminology will be correctly interpreted without verification
• Don't submit documentation without confirming all information is accurate and complete
• Don't use the system as a replacement for proper medical documentation practices

Tips & Recommendations

• Practice speaking clearly and systematically when providing patient reports
• Develop a consistent format for verbal reports to improve AI accuracy
• Include specific measurements, times, and dosages in your verbal documentation
• Use standard medical terminology and common EMS abbreviations the system recognizes
• Review generated narratives carefully as they form the permanent record
• Provide detailed feedback to help improve system performance for future use
• Remember that comprehensive initial recording reduces subsequent manual data entry

Troubleshooting & FAQs

Q: The AI isn't correctly interpreting medical terms I'm using. How can I improve accuracy?
A: Speak clearly and use standard medical terminology or common EMS abbreviations that the system recognizes. Use the feedback system to report specific medical terms or abbreviations that weren't correctly interpreted. The more feedback provided, the better the system becomes at recognizing terminology.

Q: I made multiple recordings and now have duplicate vital signs entries. How do I fix this?
A: Be aware that regenerating AI content will create new vital sign entries each time. Review all entries carefully and remove duplicates during the review process. Consider consolidating information into fewer recording sessions to minimize duplication issues.

Q: The AI suggested incorrect information for NEMSIS fields. What should I do?
A: Always review and edit AI suggestions before accepting them. You can reject incorrect suggestions, edit suggested values, or remove unwanted entries. Use the feedback system to report recurring field mapping errors to help improve system accuracy.

Q: My narrative is getting very long because I've recorded multiple times. Can I edit it?
A: Yes, the system appends new narrative sections each time you use the AI tool. You can edit the generated CHART formatted narrative to consolidate information, remove redundancy, or ensure proper flow and accuracy of the final documentation.

Q: The transcription isn't capturing everything I'm saying accurately. What can I help?
A: Speak clearly at a normal pace, use standard medical terminology, and ensure you're in a quiet environment when recording. If specific words or phrases are consistently misunderstood, report these through the feedback system with specific examples.

Q: Am I still legally responsible for the accuracy of AI-generated documentation?
A: Yes, absolutely. The system operates on a "Human-in-the-Loop" principle where you maintain full responsibility for documentation accuracy. The AI is designed to assist, not replace, proper medical documentation practices. Always review, verify, and approve all AI suggestions before finalizing reports.

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