Purpose Statement

This article provides comprehensive training guidance for EMS personnel to effectively utilize the AI voice-to-text feature in First Due's ePCR system. The AI feature dramatically reduces documentation time while maintaining accuracy and completeness of patient care reports. By speaking naturally and comprehensively during patient care, personnel can focus more on patient care rather than manual data entry, with the AI automatically organizing speech into appropriate ePCR fields.

Background Information

Feature Significance

The AI voice-to-text feature transforms traditional ePCR documentation by converting natural speech into structured patient care records. This technology recognizes medical context and terminology, allowing EMS personnel to document patient encounters in real-time while providing care.

Common Use Cases

• Real-time documentation during active patient care
• Reducing post-call administrative time
• Ensuring comprehensive and accurate patient records
• Maintaining hands-free operation during critical procedures
• Improving consistency in documentation across personnel
  

Prerequisites

• First Due ePCR module with AI feature enabled
• Device with functional microphone capability
• Stable internet connection for AI processing
• Basic understanding of medical terminology and ePCR structure
  

Training Environment Recommendation

Before beginning AI ePCR training with live patient data, we strongly recommend using the First Due Test Daily or Test environment. This allows personnel to practice AI documentation techniques without affecting their live operational environment or patient records. The test environment provides a safe space to develop proficiency with AI features, practice various scenarios, and become comfortable with the technology before implementing it in actual patient care situations. For detailed information about accessing and using test accounts, please refer to our comprehensive guide: First Due Test Accounts - What are they and how are they used?

Step-by-Step Guide

1. Establishing Core AI Documentation Principles

1. Activate Continuous Speech Pattern: Begin dictating immediately upon patient contact and maintain verbal documentation throughout the entire encounter
2. Implement Natural Medical Language: Speak using standard medical terminology as you would when reporting to receiving facilities
3. Adopt Story Flow Approach: Focus on telling the patient's story chronologically rather than attempting to fill specific form fields in order

2. Patient Demographics and Scene Documentation

1. State Primary Demographics: "Responding to [complete address], [age]-year-old [gender] patient"
2. Include Residence Information: "Lives at [home address if different from scene location]"
3. Document Patient Identifiers: "Driver's license number [number if obtained]"
4. Capture Scene Context: Include relevant scene safety or environmental factors

3. Chief Complaint and Medical History Documentation

1. Present Chief Complaint: "Patient presents with [specific complaint and characteristics]"
2. Detail Medical History: "Has history of [specific conditions], including [relevant diagnoses]"
3. List Current Medications: "Currently takes [medication name] [dosage] [unit] [administration route]"
4. Document Allergies Comprehensively: "Allergic to [environmental allergens], no known drug allergies" or specify known medication allergies
5. Identify Information Source: "History obtained from [patient/family/caregiver/other source]"

4. Physical Assessment Documentation

1. Follow Systematic Approach: Conduct head-to-toe or system-by-system assessment while verbalizing findings
2. State Positive Findings: "Neurological assessment shows [specific abnormal findings]"
3. Include Negative Findings: "Head examination shows no abnormalities"
4. Document Injury Details: "Abdominal exam reveals [injury type] with [current status - bleeding controlled, etc.]"
5. Note Assessment Progression: Reference specific times when documenting assessment changes

5. Vital Signs and Measurements Documentation

1. Time-Stamp Each Assessment: "First set of vitals at [specific time]" for each measurement series
2. State All Parameters Clearly: Include blood pressure, heart rate, respiratory rate, oxygen saturation
3. Describe Pulse Characteristics: "Pulse rhythm regularly irregular" or other specific qualities
4. Include Glasgow Coma Scale: "Glasgow Coma Scale eye response [number], verbal [number], motor [number], total [number]"
5. Note Measurement Context: Specify patient position, measurement method, or equipment used when relevant

6. Protocols and Procedures Documentation

1. Identify Active Protocols: "Following [specific protocol name] for [age category] patient"
2. Document Procedure Performance: "Performed [procedure name] at [specific time]"
3. Include Attempt Information: "One attempt successful" or specify total number of attempts
4. State Authorization Source: "Authorization per standing order protocol" or specify medical direction source
5. Identify Performing Crew Member: Note which team member performed each procedure

7. Medication Administration Documentation

1. State Complete Drug Information: "Administered [quantity] [medication name] [concentration] [administration route]"
2. Include Precise Administration Time: "At [specific time]" for each medication given
3. Document Authorization Source: "Authorization per [protocol/medical direction]"
4. Note Patient Response: Document any immediate effects, improvements, or reactions
5. Record Complications: Include any adverse reactions or administration difficulties

8. Response Timeline and Transport Documentation

1. Document Call Timeline: "PSAP call received [date/time], dispatch notified [time]"
2. Record Scene Arrival: "First EMS on scene, initial responder arrived [specific time]"
3. Note Patient Count: "Single patient at scene" or specify multiple patient situation
4. Include Unit Information: "EMS vehicle unit [number], [acuity level] dispatch priority"
5. Document Transport Destination: "Patient transported to [facility type/specific name]"

9. Crew and Equipment Information Documentation

1. Identify All Crew Members: "Crew includes [name], [certification level], [role]"
2. Include License Information: State license numbers when applicable
3. Document PPE Usage: "Wearing [specific protective equipment], no exposures"
4. Note Safety Equipment: "OSHA [specific equipment] used"
5. Record Exposure Incidents: Document any potential exposures or safety concerns

10. Final Documentation Review and Quality Assurance

1. Complete AI Processing: Allow AI system to finish processing all verbal input
2. Conduct Comprehensive Review: Check each ePCR section for completeness and accuracy
3. Fill Information Gaps: Manually add any details not captured by AI system
4. Verify Critical Data: Confirm all times, dosages, and vital measurements are correct
5. Complete Required Signatures: Add necessary electronic signatures and authorizations
   

Best Practices

Effective AI Documentation Techniques

• Start Speaking Early: Begin documentation immediately upon patient contact
• Maintain Continuous Narrative: Speak throughout the entire patient encounter
• Use Standard Medical Language: Employ terminology consistent with departmental protocols
• Include Time References: Time-stamp all significant events and assessments
• State Negative Findings: Document normal examination findings explicitly
• Follow Logical Sequence: Maintain systematic assessment organization

Advanced Documentation Strategies

• Implement Time-Stamped Entries: "At 11:31 taking second set of vitals, pulse rhythm remains regularly irregular"
• Document Trending Information: "Second assessment shows continued speech slurring, abdominal bleeding remains controlled"
• Provide Contextual Information: "Patient resides within our EMS service area, no mass casualty incident"
• Include Measurement Details: State patient position, equipment used, or measurement challenges

Critical Documentation Elements

• Allergies and Medical History: State medication and environmental allergies separately, include "no known" statements
• Medication Administration: Include complete drug name, concentration, route, and authorization source
• Scene Safety and PPE: Document all protective equipment and exposure control measures
  

Troubleshooting & FAQs

Common Issues and Solutions

Issue: AI system not capturing spoken information

• Primary Solution: Check microphone settings and reduce background noise
• Alternative Solutions: Speak more slowly for complex medical terms, repeat information using different phrasing
• Manual Backup: Enter critical information manually if AI continues to miss data

Issue: Information appearing in incorrect ePCR fields

• Primary Solution: Review each section after dictation and manually move misplaced information
• Prevention Strategy: Use section-specific keywords and provide clear context when speaking
• Optimization Tip: Develop consistent terminology that matches departmental standards

Issue: Incomplete medication or procedure documentation

• Primary Solution: Repeat complete information including all required elements
• Quality Check: Verify all mandatory fields are populated before finalizing report
• Best Practice: Use standardized reporting format for consistency
  

Frequently Asked Questions

Q: How does the AI handle complex medical terminology and abbreviations? A: The AI system is trained on medical terminology and recognizes standard EMS abbreviations. For complex or uncommon terms, speak clearly and spell out abbreviations when necessary.

Q: Can I correct mistakes while the AI is still processing? A: Yes, simply say "correction" and restate the information, or edit the text manually after AI processing is complete.

Q: What happens if the AI misinterprets critical information like medication dosages? A: Always review AI-generated content before finalizing. Critical information like dosages, times, and vital signs should be verified and corrected manually if necessary.

Q: How does the system handle multiple patient scenarios? A: Document each patient separately and clearly identify which patient you're discussing. The AI can process multiple patient information when properly structured.

Q: Is patient information secure during AI processing? A: Yes, all AI processing follows HIPAA requirements and departmental security protocols. Patient data is encrypted and not stored beyond the active session.

Use Case Examples

Multi-System Trauma Documentation

Verbal Input: "Responding to motor vehicle collision, 45-year-old female driver, chief complaint chest pain and difficulty breathing, mechanism high-speed frontal impact, patient wearing seatbelt, airbag deployed, vital signs show blood pressure 90 over 60, heart rate 120, respiratory rate 28, oxygen saturation 92% on room air. Physical assessment reveals tenderness to chest wall, clear lung sounds bilaterally, abdomen soft non-tender. Following trauma protocol, established large bore IV access, administered normal saline bolus."

Medical Emergency Documentation

Verbal Input: "Called for unconscious person, 72-year-old male found by family, history of diabetes and hypertension, takes metformin 500 milligrams twice daily and lisinopril 10 milligrams daily, blood glucose 45 milligrams per deciliter, administered dextrose 50% 25 grams IV push at 14:32 per hypoglycemia protocol, patient became alert and oriented times three, repeat blood glucose 120."

Pediatric Emergency Documentation

Verbal Input: "Pediatric patient, 8-year-old female, chief complaint fever and difficulty breathing, parents report three-day history of cough and fever, current temperature 102.4 degrees Fahrenheit, respiratory rate 32, heart rate 140, oxygen saturation 94% on room air. Physical assessment shows increased work of breathing, wheezing on auscultation. Following pediatric respiratory protocol, administered albuterol via nebulizer."

Training Exercises

Exercise 1: Complete Patient Encounter Practice

Objective: Practice comprehensive documentation from initial contact through transfer of care Instructions: Use sample scenarios to practice continuous verbal documentation including all ePCR sections Focus Areas: Maintaining narrative flow, including all required elements, proper time-stamping

Exercise 2: Vital Signs Trending Documentation

Objective: Practice documenting multiple vital sign assessments with trending analysis Instructions: Document serial vital signs with comparative language and time references Focus Areas: Time-stamping, trending language, measurement context

Exercise 3: Complex Medication Administration

Objective: Master complete medication documentation including calculations and authorization Instructions: Practice documenting multiple medications with dosage calculations and patient responses Focus Areas: Complete drug information, authorization sources, patient response documentation

Exercise 4: Multi-Patient Scenario Management

Objective: Learn to document multiple patients clearly and separately Instructions: Practice mass casualty or multiple patient scenarios with clear patient identification Focus Areas: Patient identification, separate documentation streams, triage information

Performance Optimization

Quality Assurance Checklist

1. Review AI-Generated Report: Verify all spoken information was captured accurately
2. Fill Information Gaps: Add any missing details the AI system did not capture
3. Verify Time Accuracy: Ensure all timestamps reflect actual event times
4. Check Calculations: Confirm medication dosages and vital sign calculations are correct
5. Complete Signature Requirements: Add all required electronic signatures and authorizations

Common AI Misinterpretation Prevention

• Numbers vs. Words: Say "two" instead of "2" for improved clarity
• Medical Abbreviations: Spell out complex or uncommon abbreviations
• Proper Names: Speak clearly when stating patient names, addresses, and locations
• Time Formats: Use complete time format "11:30 AM" rather than abbreviated versions