5 costly EMS documentation mistakes

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's that some crew members either don't understand or simply don't care about their professional responsibility to carefully and completely document the patient's condition at the time of transport on their patient care report.

Most simply, EMS providers need to stop using vague, meaningless words, conclusory statements and phrases that do not accurately convey — in appropriate clinical terms —the 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 PCR. And in way too many chart reviews or audits, we find no dispatch determinants or other clear indication of the patient's reported condition at the time of dispatch.

Dispatch information, including the patient's 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't have this critical piece of their patient care clearly and consistently documented on the PCR some 14 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's reported condition, which crews must clearly document on their PCR.

2. Insufficient narrative of the patient's 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 — such as, "patient transported without incident."

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 reader include the patient's mobility status, as well as the patient's ability to assist with the transfer to and from the stretcher and how that transfer was accomplished-and why. The PCR narrative must also answer how the patient's ability to care for themself compares to the patient's normal condition.

Also answer, what prompted the patient to call for an ambulance" When did the patient's problems start" How have the patient's symptoms evolved"

We suggest that ambulance services obtain and crew members read, whenever possible, hospital admission summaries for the patients they transport.

That doesn't 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's 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's 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 "per protocol" 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's PCR is part of that patient's medical record, not simply an internal document.

Crew members should not assume that those reading their PCR know their organization's protocols. The medical findings that suggest the need for each intervention, as well as the patient's 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, "Transported patient for higher level of care" 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's pain. EMTs and paramedics should always describe a finding or complaint of pain by documenting completely the Onset, Provocation, Quality, Radiation, Severity and Time (OPQRST), as well as the patient's pain rating on a scale of zero to 10.

The word "pain" 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.

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