Clinical records are crucial for patient safety, continuity of care, and reflect the quality of care. In disasters, their importance increases due to limited patient information and complex scenarios. PT EMT clinical records should follow WHO recommendations and SOPs to ensure good practices and patient safety, especially during care transitions. Currently, PT EMT records are paper based until the Emergency Medical Team Operating System (EOS) digital system is implemented.

The aim was to review PT EMT’s clinical records from 2023 to assess adherence to procedures, identify improvement areas, provide feedback to professionals, and promote a culture of patient safety and continuous improvement.

Ten clinical records were randomly selected from each PT EMT deployment in 2023, totaling 60 records analyzed and registered using a specific checklist.

Records were missing information for: mission identification (35%), patient nationality (52%); contact details (100%); event date (12%); event type (57%); event-mission relationship (87%); time of 1st triage (43%); triage result (25%); patient assessment time (33%); patient history (48%); allergies (45%); usual medication (57%); diagnosis (30%); medication prescription and administration (21%); procedures carried out (44%;, patient situation decision (43%); physician signature (12%) and ID number (53%; decision date (22%), and decision time (33%).

To standardize patient clinical recording, we planned and implemented: inclusion of this topic during briefings in deployments and in the PT EMT annual training plan; elaboration of a specific SOP, update record templates; conduct a workshop during DIRECT Course. The audits will be repeated with 2024 clinical records to evaluate the measures’ effectiveness.