AI- assisted ePCR Documentation Guide
Purpose
- To provide useful information when using AI for ePCR Documentation.
Featured Article
- For full guide select on the Attachment at bottom of the page.
FirstDue AI-Powered ePCR Documentation FAQs
General Information
Q: What is the AI-assisted ePCR Documentation feature?
A: The AI-assisted ePCR Documentation feature streamlines creating Patient Care Reports by allowing EMS providers to record patient care details verbally. This feature combines medical-grade speech transcription with AI processing to automatically populate NEMSIS ePCR fields, significantly reducing documentation time.
Q: How many NEMSIS data fields can the system populate?
A: The system can populate up to 100 different NEMSIS data fields.
Q: What types of information can the system process?
A: The system processes various types of information including vital signs, medications administered, physical assessments, patient history, treatments provided, and transport information.
Using the Feature
Q: How do I start using the AI Transcript tool?
A: To start using the AI Transcript tool:
- Launch the AI Transcript tool
- Click the record button to begin speaking
- Provide a verbal report of the patient encounter
- After recording, click Analyze to process your recording
- Review the suggestions from the AI Assistant.
- If needed, make changes while reviewing.
- Accept those suggestions.
Q: What should I include in my verbal report?
A: Think of your verbal report as a combination of your entry note over the radio, a handoff report to the ER staff, and a verbal summary of the incident. The more information you provide, the less you may need to type or select later.
Q: Can I use medical abbreviations and EMS terminology?
A: Yes, the system supports both formal medical terminology and common EMS abbreviations.
Q: Can I make multiple recordings during an incident?
A: Yes, you can record multiple times during an incident. However, be aware that regenerating will create new vital sign entries and make additions to your narrative.
Review and Editing
Q: Do I need to review the AI suggestions?
A: Yes, all AI suggestions appear in a review interface. You are responsible for verifying the accuracy of all information.
Q: What options do I have when reviewing AI suggestions?
A: Users can:
- Accept or reject individual field suggestions
- Edit suggested values
- Remove unwanted entries
Q: How are physical assessment fields handled?
A: Physical assessment fields must be reviewed in the main chart, not during the review process.
Q: What happens to the narrative section?
A: The Narrative section will automatically generate a CHART formatted narrative based on the transcript provided.
Q: What happens when I use the AI tool multiple times for the same incident?
A: Each time you use the AI tool, the system will append your narrative. In other words, it will add a new section to the end of your previous narrative.
Data Security & Compliance
Q: Is the system HIPAA compliant?
A: Yes, the system is fully HIPAA compliant.
Q: How is patient data handled?
A: All transcriptions are encrypted in transit and at rest. The transcription service runs in a dedicated, secure environment, and no patient data is used for AI training.
Q: How is user feedback used?
A: Feedback is used only to improve prompt engineering.
Legal Considerations
Q: Who is responsible for the accuracy of the documentation?
A: The provider maintains full responsibility for the accuracy of the documentation. This system operates on a "Human-in-the-Loop" principle, meaning all AI suggestions must be reviewed and approved by the provider.
Q: Is this system meant to replace proper medical documentation?
A: No, the system is designed to assist, not replace, proper medical documentation.
Feedback and Support
Q: How can I provide feedback about the feature?
A: Use the feedback system to report issues or suggest improvements. Include information about accuracy of transcription, correctness of field mapping, missing or incorrect terminology, feature suggestions, and any issues encountered.
Q: What should I do if medical terminology isn't correctly interpreted?
A: Report any medical terminology or abbreviations that weren't correctly interpreted through the feedback system.
Q: What specific feedback is most helpful?
A: The most helpful feedback includes specific examples of what worked well or needs improvement.
Best Practices
Q: What are some best practices for using this feature?
A: Some best practices include:
- Speak clearly and provide complete information
- Review AI suggestions before accepting
- Use the feedback system to report any misinterpretations or suggestions for improvement
- Always review and edit when needed the AI-suggested entries
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