Article updated October 2, 2018
By Steve Johnson
One of the most frustrating scenarios for EMS agencies is the denial of coverage for ambulance transport for far too many patients.
In the vast majority of cases our clients share with us, the primary reason patients are deprived of coverage is not that ambulance transport was medically unnecessary. Rather, it鈥檚 that some crew members either don鈥檛 understand or simply don鈥檛 care about their professional responsibility to carefully and completely document the patient鈥檚 condition at the time of transport on their electronic patient care report - a medical record.
Most simply, EMS providers need to stop using vague, meaningless words, conclusory statements and phrases that do not accurately convey 鈥� in appropriate clinical terms 鈥攖he true condition of the patient at the time of service.
Here are the five most common EMS documentation mistakes we see and how EMS providers can stop making these costly mistakes.
1. Facts surrounding the dispatch undocumented
Many times when an ambulance responds to a 911 call, that simple fact is missing from the ePCR. And in way too many chart reviews or audits, we find no dispatch determinants or other clear indication of the patient鈥檚 reported condition at the time of dispatch.
Dispatch information, including the patient鈥檚 reported condition at the time of dispatch, has been a critical component of good quality patient care documentation since 2002. How is it that so many organizations still don鈥檛 have this critical piece of their patient care clearly and consistently documented on the PCR so many years later?
Organizations, whether their dispatch is internal or external, need to ensure that they have dispatch protocols, approved by their medical director, that are clearly understood at all levels of the organization. Dispatchers then must clearly communicate to the crews the patient鈥檚 reported condition, which crews must clearly document on their PCR.
2. Insufficient narrative of the patient鈥檚 condition at the time of transport
Far too frequently we see PCR narratives that do little more than state where the patient was picked up from, where they were delivered to and some statement that indicates that the crew left the patient no worse off than they found them 鈥� such as, 鈥減atient transported without incident.鈥�
This is especially true in the case of non-emergency transports.
For every transport, whether emergency or non-emergency, the PCR narrative must state the facts accurately, objectively and completely so that the reader can answer the question: Was transport of this patient by means other an ambulance contraindicated?
Other questions that should never go unanswered for the narrative reader include the:
- Patient鈥檚 mobility status
- Patient鈥檚 ability to assist with the transfer to and from the stretcher
- Method used for the transfer and why.
The PCR narrative must also answer how the patient鈥檚 ability to care for themself compares to the patient鈥檚 normal condition.
Also answer, what prompted the patient to call for an ambulance? When did the patient鈥檚 problems start? How have the patient鈥檚 symptoms evolved?
We suggest that ambulance services obtain and crew members read, whenever possible, hospital admission summaries for the patients they transport.
That doesn鈥檛 have to be all the tests that were performed and the final diagnosis, but simply the history of present illness and summary of the patient鈥檚 condition upon arrival. These admission summaries will often provide concrete examples of how professional medical records are expected to be written and the information that may be missing from their PCR for that same patient.
Many times if crews had taken the time to understand their patient鈥檚 presentation, and documented those findings, the ambulance service would have far less problems verifying and supporting the care they provided when seeking reimbursement.
3. Vague explanation of specific interventions and procedures performed
Too many times we find nothing more than 鈥減er protocol鈥� to explain why a cardiac monitor was applied, an IV was initiated or some other procedure was performed. Just like the ambulance service must be medically necessary to be reimbursed by Medicare and other payers, the treatments provided must also be medically necessary.
Interventions and procedures should be performed in response to specific patient assessment findings, not simply because some protocol exists. Crew members must understand that the patient鈥檚 PCR is part of that patient鈥檚 medical record, not simply an internal document.
Crew members should not assume that those reading their PCR know their organization鈥檚 protocols. The medical findings that suggest the need for each intervention, as well as the patient鈥檚 response to that intervention, should be clearly documented.
4. No explanation for EMS-specific care and treatment
This is important with regard to two areas. First, is clearly explaining the transport itself and the service or care the patient required during the transport that could not be provided other than by trained medical professionals in an ambulance.
Second, in the case of a patient being transported from one facility to another, what specific services does the patient require that are not available at the facility of origin?
Simply stating, 鈥淭ransported patient for higher level of care鈥� tells the reader nothing. The PCR must make clear the care the patient required at the destination facility and why that care could not be provided in the facility of origin.
In addition, the PCR must show what professional medical care the patient required during transport to that facility.
5. Inadequate description of patient complaints or findings
The most common example of an inadequately described or quantified complaint or finding is with regard to a patient鈥檚 pain. EMTs and paramedics should always describe a finding or complaint of pain by documenting completely the Onset, Provocation, Quality, Radiation, Severity and Time (), as well as the patient鈥檚 pain rating on a scale of zero to 10.
The word 鈥減ain鈥� on a PCR is a trigger to remind the EMS provider to fully describe and document that pain.
Hemorrhage is another common finding that is inadequately described. Always describe the location and size of any wound, and quantify of blood loss.
Again, these are just two examples. Good PCR documentation will not just state conclusions or findings. It always describes and quantifies those findings accurately, honestly and objectively.
These five mistakes represent the most common documentation shortcomings we see on PCRs. Sadly, it is due to poor or incomplete documentation, and not an actual lack of medical necessity for an ambulance, that far too many patients are deprived of the coverage they deserve and too many ambulance services are deprived of fair compensation for the care they provide.
