Self-Reported Completeness of Neurological Documentation in Prehospital Emergency Care: Associations With Neurological Training and Professional Experience

Abstract

Background

Neurological assessment is a critical component of prehospital emergency care, particularly in time-sensitive conditions including stroke and traumatic brain injury. Neurological documentation practices in this setting remain insufficiently characterized. This study aimed to evaluate self-reported completeness of neurological documentation among paramedics, then examine its associations with neurological training and professional experience.

Material/Methods

A cross-sectional study was conducted between June 2025 and March 2026 among 348 paramedics working in emergency medical services in southeastern Poland. Data were collected using a structured electronic questionnaire. Self-reported documentation completeness was assessed using a composite score based on the reported frequency of documenting 7 neurological examination elements rated on a 5-point Likert scale (range: 7–35).

Results

Overall self-reported documentation completeness was moderate (mean score: 24.57). Respondents frequently reported documenting basic neurological parameters (eg, level of consciousness: 81.0%); more detailed components were reported less consistently. Only 9.2% of respondents reported consistently documenting temporal neurological changes. The greatest self-reported deficiencies involved documentation of temporal neurological changes and detailed focal neurological findings. Participation in neurological training was associated with higher completeness scores (26.20 vs 23.24; P < 0.001). Self-reported documentation completeness was positively correlated with professional experience (ρ = 0.359; P < 0.001).

Conclusions

Self-reported neurological documentation completeness among paramedics was moderate and selective; self-reported rates were lowest for dynamic and detailed focal neurological components. Participation in neurological training and greater professional experience were associated with higher self-reported documentation completeness scores. These findings suggest that standardized documentation protocols and targeted educational interventions contribute to more consistent neurological documentation practices in prehospital settings.

Introduction

Neurological assessment constitutes a fundamental component of patient evaluation in the prehospital setting, particularly in acute, time-critical conditions such as stroke, traumatic brain injury, seizures, altered mental status, and metabolic or toxic disturbances [1]. In such scenarios, early identification of neurological impairment extends beyond diagnostic value to directly influence triage prioritization, prehospital decision-making, and the selection of appropriate treatment pathways, including rapid transport to specialized centers [2]. Prehospital care is increasingly recognized as an integral component of the acute care continuum, in which the accuracy and completeness of the initial clinical assessment may substantially affect downstream clinical outcomes [3].

However, neurological examination in prehospital practice is inherently constrained by environmental and operational factors. Emergency medical teams are required to perform rapid yet clinically meaningful assessments under conditions of limited time, incomplete patient history, variable patient cooperation, and frequently suboptimal physical environments [4–6]. Consequently, clinicians rely on a combination of structured tools, such as the Glasgow Coma Scale (GCS), and focused neurological observations, including pupillary responses, focal deficits, and speech disturbances. Although these elements form the core of early neurological evaluation, their consistent translation into formal documentation remains suboptimal [7,8].

Clinical documentation in prehospital care fulfills several critical roles. It serves as the primary communication interface between prehospital providers and receiving hospital teams; supports medicolegal accountability; and provides essential data for quality assurance, epidemiological analyses, and system-level improvement [9]. In the context of neurological assessment, documentation assumes additional importance due to the dynamic and often rapidly evolving nature of neurological deficits. Subtle changes in consciousness, emerging focal signs, or early indicators of deterioration may be transient and—if not recorded—permanently lost. Accordingly, incomplete or selective documentation may disrupt continuity of care, impair clinical decision-making in the emergency department, and ultimately compromise patient safety [10–12].

Despite its recognized importance, a persistent discrepancy exists between neurological assessment performed in the prehospital setting and its documentation. Whereas fundamental parameters, such as level of consciousness, are routinely recorded, more detailed findings—including focal deficits, pupillary responses, and temporal changes—are frequently omitted. This discrepancy reflects not only operational constraints but also cognitive processes associated with high-workload environments, in which clinicians prioritize information perceived as immediately actionable. Although such prioritization is adaptive in time-critical settings, it may lead to systematic underdocumentation of clinically relevant details [13].

Documentation practices are further influenced by a complex interplay of individual and organizational factors. At the individual level, professional experience, training, and familiarity with neurological assessment substantially affect both the depth of examination and likelihood of documentation. More experienced clinicians often demonstrate improved pattern recognition and diagnostic confidence, facilitating more comprehensive documentation; variability in training—particularly concerning prehospital neurology—may contribute to inconsistencies in practice [14].

Organizational determinants, including team composition, workload, case severity, and operational pressure, may further limit opportunities for detailed documentation, especially in high-acuity situations [15]. Additionally, the structure of documentation systems plays a pivotal role because unstructured formats may promote omissions, whereas standardized templates have been shown to improve documentation completeness and consistency [16].

Importantly, documentation should not be regarded as a passive record but rather as an integral component of clinical reasoning [17]. The process of documentation supports diagnostic reasoning, enhances situational awareness, and facilitates effective communication among providers. In this context, incomplete documentation may both reflect and perpetuate deficiencies in clinical assessment [17].

Moreover, the increasing emphasis on quality metrics and data-driven evaluation in emergency medical services highlights the critical role of accurate documentation [18,19]. Incomplete neurological records can lead to misclassification of patient status, distortion of quality indicators, and suboptimal system-level decision-making [18,19].

Previous studies have examined selected aspects of prehospital neurological assessment and documentation, particularly use of the GCS and general neurological evaluation practices [20,21]. Fewer studies have explored the multidimensional nature of self-reported neurological documentation practices, including differential reporting of individual neurological examination components and their associations with practitioner-related factors such as training and professional experience within specific prehospital care settings [2,22]. Furthermore, the relationship between self-reported documentation completeness and perceived organizational or operational barriers remains insufficiently characterized in regional emergency medical service populations.

Therefore, this study aimed to evaluate self-reported completeness of neurological examination documentation among paramedics working in prehospital emergency care and to identify factors associated with variability in documentation practices.

We hypothesized that (1) overall self-reported neurological documentation completeness would be moderate to low, with higher reporting frequencies for basic neurological parameters than for detailed or dynamic neurological findings; and (2) participation in neurological training and greater professional experience would be associated with higher documentation completeness scores.

Rather than addressing a completely unexplored area, the present study was designed as an incremental contribution to previous survey-based research by quantifying multidimensional self-reported neurological documentation practices and their associations with training and professional experience in a regional prehospital workforce.

Material and Methods

Study Design and Setting

This cross-sectional observational study was conducted between June 2025 and March 2026 among emergency medical personnel working within the State Emergency Medical Services system in the Podkarpackie Voivodeship, Poland.

The present manuscript exclusively reports the questionnaire-based component of the study. Data were collected using a structured electronic questionnaire developed by the investigators to assess self-reported completeness of neurological examination documentation practices in prehospital care.

This study was approved by the Bioethics Committee of the State Academy of Applied Sciences in Przemysl (approval no. 8/2024; issued August 1, 2024). The study was conducted in accordance with the principles of the Declaration of Helsinki. Participation was voluntary and anonymous; no personally identifiable data were collected at any stage of the study. All responses were fully anonymized before analysis, and completion of the questionnaire was considered to constitute implied informed consent.

Participants and Eligibility Criteria

The study included paramedics actively working in emergency medical teams. Eligibility criteria required participants to be currently practicing in emergency medical services, either as employees or while performing duty shifts within emergency medical teams, and to have a minimum of 6 months of professional experience in the prehospital setting. Only individuals who voluntarily agreed to participate and completed the questionnaire in full were included in the final analysis. Participants were excluded if they did not provide consent, had fewer than 6 months of experience in emergency medical teams, were not actively practicing at the time of the study, or submitted incomplete or duplicate questionnaires.

Data Collection Tool

Data were collected using an investigator-developed questionnaire designed specifically for this study. The instrument consisted of 30 items organized into 6 thematic sections: demographic characteristics (M1–M7), core neurological assessment practices (Q8–Q15), clinical context and priorities (Q16–Q17), self-assessment of knowledge and confidence (Q18–Q19), perceived barriers to neurological assessment and documentation (Q20–Q23, Q28), and system-level evaluation (Q24–Q27, Q29–Q30). The questionnaire was developed specifically for the purposes of the present study; it was not subjected to formal psychometric validation or pilot testing prior to data collection. Accordingly, formal measures of reliability and internal consistency for the complete instrument were not established.

Demographic variables included sex, age, education level, years of professional experience, type of emergency medical team, workplace setting, and participation in neurological training within the previous 2 years. Most questionnaire items were assessed using a 5-point Likert scale (ranging from “never” to “always” or from “strongly disagree” to “strongly agree”), allowing quantitative analysis of frequency- and perception-based responses.

The core section of the questionnaire focused on the frequency of documenting key neurological examination elements, including level of consciousness, GCS score, pupillary assessment, presence of paresis or paralysis, speech disturbances, lateralization of neurological symptoms, and temporal changes in neurological status during the intervention. Although the questionnaire included additional perception- and system-level items, the present analysis focused on the documentation completeness score and its associations with neurological training and professional experience.

The questionnaire was electronically distributed to 648 eligible individuals. To maximize the response rate, reminder messages were sent 2 weeks after the initial invitation and 1 week before survey closure. Of the 648 invited participants, 348 completed the questionnaire in full and were included in the final analysis, corresponding to a response rate of 53.7%. All responses were anonymized before analysis.

Outcome Measures

The primary outcome of the study was self-reported completeness of neurological examination documentation. This was operationalized using a composite completeness score derived from responses to 7 key items (Q9–Q15), each corresponding to a specific component of neurological assessment documentation. Q8 was excluded from the composite score because it evaluated general neurological assessment practice, rather than the frequency of documentation of a specific neurological examination component. Each item was rated on a 5-point Likert scale (1 = never, 5 = always), resulting in a total score ranging from 7 to 35; higher scores indicated greater self-reported documentation completeness. The completeness score was treated as a continuous variable in the statistical analyses. For descriptive purposes, documentation completeness was additionally categorized into 3 levels (low, moderate, and high) based on tertile distribution.

Secondary analyses evaluated associations between self-reported documentation completeness and selected practitioner-related factors, particularly neurological training and professional experience.

Statistical Analysis

Statistical analyses were performed using StatPlus software (AnalystSoft, Brandon, FL, USA). Continuous variables are presented as mean ± standard deviation for normally distributed data or median with interquartile range for nonnormally distributed data. Categorical variables are presented as counts and percentages.

Data distribution normality was assessed using the Shapiro-Wilk test. Because most continuous variables did not meet the assumption of normality, nonparametric statistical methods were applied. Comparisons between 2 independent groups were conducted using the Mann-Whitney U test; comparisons among more than 2 groups were performed using the Kruskal-Wallis test followed by Dunn’s post hoc test with Bonferroni correction, when applicable. Effect sizes were calculated using r for the Mann-Whitney U test and η² for the Kruskal-Wallis test.

Associations between categorical variables were evaluated using the chi-square test. Correlations between variables were assessed using Spearman’s rank correlation coefficient (ρ) and interpreted according to standard thresholds. Two-tailed P-values < 0.05 were considered statistically significant.

Results

Study Population Characteristics

In total, 348 paramedics were included in the analysis. The majority of respondents were men (63.8%), whereas women constituted 35.3% of the study population. The most represented age group was 30 to 39 years (37.9%), followed by participants aged 20 to 29 years (27.3%).

Regarding educational background, 56.0% of respondents held a bachelor’s degree and 38.5% held a master’s degree. The largest proportion of participants had more than 10 years of professional experience (30.5%). Most respondents worked in basic emergency medical teams (65.5%), and 44.8% reported participating in neurological training within the previous 2 years.

Responses not within the sex and educational categories stated above constituted the difference between the reported percentages and 100%.

Overall Completeness of Documentation

The overall level of self-reported completeness of neurological examination documentation was moderate. The mean completeness score was 24.57 (median, 25.00; range, 14–33). Based on tertile classification, 61.2% of respondents demonstrated moderate completeness; 23.9% and 14.9% displayed high and low completeness, respectively.

Frequency of Individual Neurological Components

The self-reported frequency of documentation of neurological examination components is presented in Table 1. Assessment of consciousness was the most consistently documented neurological parameter; 81.0% of respondents reported that they “always” or “often” documented this element. GCS assessment was reported to be documented “always” or “often” by 58.0% of participants.

Table 1.

Self-reported frequency of documentation of neurological examination components.

Parameter	Always (%)	Often (%)	Sometimes (%)	Rarely (%)	Never (%)
Consciousness	37.6	43.4	17.5	1.4	0.0
GCS	22.7	35.3	31.6	8.9	1.4
Pupillary assessment	13.2	28.4	32.8	19.0	6.6
Paresis/paralysis	16.7	36.2	32.2	13.2	1.7
Speech disturbances	17.2	32.2	37.6	11.2	1.7
Lateralization	16.1	31.0	33.0	17.0	2.9
Dynamics of changes	9.2	24.4	34.2	24.1	8.0

Abbreviation: GCS, Glasgow Coma Scale.

More detailed neurological examination components were reported less consistently. Pupillary assessment was reported to be “always” documented by only 13.2% of respondents, whereas paresis/paralysis, speech disturbances, and lateralization were most commonly documented “often” or “sometimes.” The least frequently reported element was documentation of temporal neurological changes. Only 9.2% of respondents reported “always” documenting neurological changes over time, whereas 32.1% reported doing so “rarely” or “never.”

Documentation Completeness According to Neurological Training

The distribution of documentation completeness categories according to neurological training status is presented in Table 2. A statistically significant association was observed between participation in neurological training and the level of self-reported documentation completeness (χ² = 52.00; df = 2; P < 0.001). Respondents who had undergone neurological training were more likely to achieve high completeness scores than those without prior training.

Table 2.

Documentation completeness according to neurological training.

Training status	Low	Moderate	High
No	45	126	21
Yes	7	87	62

Documentation completeness scores according to neurological training status are presented in Table 3. Participants who had undergone neurological training demonstrated significantly higher completeness scores than those without prior training (mean, 26.20 ± 3.43 vs 23.24 ± 3.43; median, 27 [Q1–Q3: 24–29] vs 23 [Q1–Q3: 21–25]; Mann-Whitney U = 7890.5; P < 0.001; r = 0.40), indicating a moderate effect size. Frequent GCS documentation (“often” or “always”) was reported by 66.7% of respondents who had undergone neurological training compared with 51.0% of those who lacked training (χ² = 8.63; df = 1; P = 0.003).

Table 3.

Documentation completeness score according to neurological training.

Neurological training	n	Mean ± SD	Median (Q1–Q3)	Mean rank
Yes	156	26.20 ± 3.43	27 (24–29)	218.09
No	192	23.24 ± 3.51	23 (21–25)	138.16

Abbreviations: n, number of respondents; Q1–Q3, first and third quartiles (interquartile range); SD, standard deviation.

Documentation Completeness According to Professional Experience

Documentation completeness scores according to years of professional experience are presented in Table 4. Self-reported documentation completeness significantly differed among professional experience groups (Kruskal-Wallis H = 54.04; df = 3; P < 0.001; η² = 0.15), indicating a moderate effect size. The lowest completeness scores were observed among paramedics with 6 months to 2 years of professional experience; the highest scores were observed among respondents with more than 10 years of professional experience.

Table 4.

Documentation completeness score according to years of professional experience.

Years of professional experience	n	Median (Q1–Q3)	Mean rank
6 months to 2 years	68	22 (19–24)	100.85
3–5 years	89	25 (22–27)	167.74
6–10 years	85	25 (23–28)	197.71
> 10 years	106	26 (24–29)	208.81

Abbreviations: n, number of respondents; Q1–Q3, first and third quartiles (interquartile range).

Dunn’s post hoc pairwise comparisons with Bonferroni correction demonstrated significant differences between the 6 months to 2 years group and the 3 to 5 years group (P < 0.001), the 6 months to 2 years group and the 6 to 10 years group (P < 0.001), the 6 months to 2 years group and the more than 10 years group (P < 0.001), and the 3 to 5 years group and the more than 10 years group (P = 0.004). No significant differences were observed between the 3 to 5 years and 6 to 10 years groups or between the 6 to 10 years and more than 10 years groups.

A significant positive correlation was identified between years of professional experience and documentation completeness score (Spearman ρ = 0.359; P < 0.001), indicating a moderate association between professional experience and self-reported documentation completeness.

Discussion

The present study provides a detailed evaluation of self-reported neurological examination documentation practices in the prehospital setting and identifies factors associated with perceived documentation completeness. The findings suggest that respondents perceive neurological documentation practices as incomplete and selectively focused, with substantial variability across individual examination components and practitioner characteristics. Similar discrepancies between performed assessments and recorded findings in emergency medical services have been observed in previous studies, highlighting persistent documentation gaps in prehospital care [2].

A key finding in the present study was that respondents most frequently reported documenting fundamental elements of neurological assessment, particularly level of consciousness and GCS. This likely reflects their central role in prehospital triage and decision-making, where rapid assessment of consciousness directly determines urgency and transport pathways. Previous research has shown that the GCS remains the most widely used and documented neurological assessment tool in prehospital care, despite recognized variability in its application and interpretation [23]. In contrast, more detailed neurological components—such as pupillary assessment, focal deficits, lateralization, and especially the temporal evolution of neurological signs—were reported to be documented considerably less frequently. This pattern suggests prioritization of essential, time-critical parameters; more complex or time-intensive elements may be more likely to be omitted from documentation.

Such selective reporting patterns may be interpreted within the framework of cognitive load theory, which posits that, under high-pressure conditions, clinicians prioritize immediately actionable information [24]. In the prehospital environment—characterized by time constraints, limited diagnostic resources, and high patient acuity—this approach may represent an adaptive response. However, it can also contribute to underdocumentation of clinically relevant findings. Importantly, this phenomenon may reflect not only limitations in documentation practices but also a partial disconnect between clinical assessment and its formal documentation [25].

The particularly low self-reported frequency of documenting temporal changes in neurological status may represent a clinically relevant gap in documentation practices. Dynamic neurological assessment is essential for the early detection of deterioration, especially in conditions such as stroke or traumatic brain injury. Current evidence emphasizes that timely recognition of neurological decline is critical to optimize outcomes in acute neurological emergencies [26]. Inadequate documentation of such changes may plausibly contribute to the loss of clinically important information during handoff, misinterpretation of disease progression, and delays in therapeutic decision-making.

A major finding of the present study is the moderate association between neurological training and self-reported documentation completeness. Respondents who had undergone neurological training reported significantly higher completeness scores and more frequent GCS documentation than those without such training. This observation is consistent with previous studies indicating that targeted education improves adherence to clinical protocols and enhances the quality of care in emergency settings [14]. Notably, the association between training and documentation was observed not only for the overall completeness score but also for GCS documentation, suggesting that structured education can influence specific documentation behaviors in clinical practice.

Professional experience was also associated with higher self-reported documentation completeness. The observed positive correlation between years of experience and documentation completeness score suggests that cumulative clinical exposure may facilitate more comprehensive assessment and documentation practices. This finding aligns with evidence demonstrating that clinical expertise enhances diagnostic accuracy and efficiency in emergency medicine [14]. Concurrently, it highlights a potential vulnerability among less experienced practitioners, whose assessment and documentation processes may be less structured, underscoring the need for targeted educational and supervisory support.

In addition to individual factors, the findings emphasize the importance of organizational and system-level determinants. Variability in self-reported documentation of more complex neurological elements may reflect perceived operational constraints such as time pressure, patient acuity, and workload. Previous studies have shown that high workload and environmental stress can negatively affect documentation quality in emergency medical services [27]. Moreover, the structure of documentation systems appears to play a critical role. Unstructured or poorly designed templates may facilitate omissions, whereas standardized formats have been associated with improved documentation completeness and reduced information loss [16].

Taken together, these findings highlight a discrepancy between the recognized importance of neurological assessment and the perceived consistency of its documentation in prehospital practice. Whereas respondents appeared to acknowledge the clinical relevance of neurological assessment, cognitive, organizational, and system-level barriers appeared to limit comprehensive documentation. This perceived gap may plausibly affect continuity of care, interprofessional communication, and the reliability of clinical information transferred between providers, although patient-level outcomes were not directly assessed in the present study [2,9].

An important interpretive caveat warrants explicit acknowledgment: the observed low self-reported frequency of documenting particular neurological components should not be assumed to reflect an equally low frequency of performing those examinations. It is plausible that paramedics routinely perform more comprehensive neurological assessments than they formally document; documentation deficiencies arise from time constraints, inadequate template design, or cognitive prioritization under high-acuity conditions, rather than from omission of the clinical assessment itself. This distinction between assessment and documentation practices is methodologically important and should be considered when interpreting the present findings. Self-report surveys capture perceived documentation behavior and may underestimate or overestimate actual practice; accordingly, the present results reflect self-reported documentation completeness and cannot be generalized to the actual frequency or quality of neurological examinations performed in the field [28].

From a practical perspective, the observed associations suggest several approaches that may support improvements in neurological documentation practices, pending empirical validation. The implementation of standardized documentation templates could reduce omissions of key neurological elements. Expansion of targeted educational programs in prehospital neurology may be particularly beneficial for less experienced practitioners. The integration of documentation into clinical workflows—for example, through digital decision-support tools—may help reduce cognitive burden, although the effects of such interventions on actual documentation quality require prospective evaluation [29].

This study has several limitations that should be considered when interpreting the findings. First, the study was based on self-reported responses, introducing the possibility of response bias, such as overestimation of actual clinical practice. Thus, discrepancies between reported and actual documentation behaviors cannot be excluded. Second, the study was conducted within a single geographic region, which may limit the generalizability of the findings to other emergency medical systems with different organizational structures or training standards. Third, the study exclusively relied on questionnaire-based data, rather than direct evaluation of medical records or objectively verified clinical documentation. Therefore, the findings should be interpreted as reflecting self-reported documentation practices rather than actual documentation behavior. Fourth, although useful for quantitative assessment, the composite completeness score may not fully capture qualitative aspects of the neurological examination or the clinical relevance of individual components. Finally, the cross-sectional design precludes causal inference; consequently, the observed associations—particularly those related to training and professional experience—should be interpreted as correlational rather than causal.

Conclusions

Self-reported neurological examination documentation completeness among paramedics in emergency medical services was moderate and selective, with the lowest self-reported rates for documentation of dynamic neurological changes and detailed focal neurological findings. Greater professional experience and participation in targeted neurological training were associated with higher self-reported documentation completeness scores. Based on these self-reported associations, standardized documentation protocols and focused educational interventions represent plausible approaches for improving neurological documentation practices in prehospital care; their effectiveness requires prospective evaluation.