Tip of the month:
Bill based on Medical Necessity
Bill all EMS services based on the medical necessary level of care provided at the time of transport. The dispatch information alone will not drive the level of care of for the decision of ALS vs BLS services.
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6 Steps to Rescuing Your
Patient Care Reports
by Grant Helferich
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As professionals we pride ourselves on providing the best prehospital care to those entrusting us with their lives. We have spent countless hours in the classroom, riding on ambulances, and taking tests in order to become certified in our profession. In many states, paramedics are required to receive an associate's degree to be eligible to take the certification exam. However, despite all of this training, many seem to have lost or forgotten the essential elements of documentation 101.
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The following are 6 check-listed questions you should ask yourself before submitting your patient care report:
- Are your descriptions detailed enough?
- Are the abbreviations you used appropriate and professional?
- Is your PRC free of grammar and spelling errors?
- Is the Chief Complaint correct?
- Is your Impression specific enough?
- Are all other details in order?
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1. Check your descriptions
Upon the completion of every ambulance call, a patient care report (PCR) must be generated to document all events that occurred. This includes a detailed assessment of the situation and a full recounting of the treatment administered to the patient. It is both specific and informative; free of ambiguity and negligence. But yet, after all of our extensive training, the best we can do in our detailed assessment is "patient has pain to the arm"?
-Which arm is the patient having pain in?
-Is it the upper or lower part of the arm?
-What was the timeline of the incident?
-What was your assessment when you palpated the arm?
-Were there distal pulses during your assessment?
There are many fine details that should be documented in your PCR. "Patient has pain to the arm" will simply not do. For this reason, a documentation policy should be in place.
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There has been a steady degradation of the communication skills in the United States, especially with the introduction of instant digital communication. They have reduced the English language to gibberish. This language should not have a place in a PCR.
Adding to this communication degeneration is the misuse of medical abbreviations in PCRs. Abbreviations should be avoided in a professional report due to easy confusion in a court of law or by insurance providers.
Some examples of abbreviations that should never be used include:
P.U.T.S. Patient unable to sign.
T.M.B. Too many birthdays.
F.L.B's. Those funny looking beats in an ECG.
HTK. Higher than a kite.
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3. Check (and recheck) spelling and grammar
Your PCR should paint a picture, but this is impossible to do without proper English. Besides not being accurate or professional, incorrect English may very well lead a reader to believe something false. For example, there may be confusion (and laughter) if a report was to say "patient fainted and her eyes rolled around the room". This is a humorous example, but dire consequence can follow confusing reporting.
Reporting should be free of misspellings and the understanding of what you are trying to say should be clear to the reader. The trauma surgeon should have a good understanding of the mechanism of injury that brought the patient to his emergency room upon skimming your report.
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Grant Helferich
Grant is employed as EMS Advisor/Business Development Manager with Omni EMS Billing in Wichita, Kansas. He is a former member of the KEMSA Board and has also served as the treasurer and president of the KEMSA Administrator's Society. He was certied as an EMT, EMT-I, M.I.C.T. , and T.O. II. Grant has worked as an EMT, EMT-I, M.I.C.T., Field Supervisor, Flight Paramedic, Cardiovascular Specialist, Assistant Director, and Director of EMS.
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I've never really cared for the month of February. The two months of winter prior to this point usually leave me so somnolent from the colorless outdoors and captive cold that I can't even pronounce a word like somnolent, much less recall what it means
... read more.
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Everyone knows that good documentation should be a priority for EMS administrators, manager, and staff. But what should be done when performance doesn't quite meet the standard?
The first plan of attack should be to handle the mistake with integrity. Own up to your mistakes
...read more.
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To date, most accounts of ICD-10 implementation are good ones. Claims are processing, providers are being paid, denials are minimal; it was all much ado about nothing. Or was it? For some unlucky practices and organizations, things did not (and are not) going quite so well.
... read more.
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Omni Billing Services was founded in 1993 and has steadily built a reputation across the country for vastly improving the billing revenue of EMS organizations and medical offices by providing exemplary customer service in the process.
Our mission everyday is to maximize our clients' time and revenue through the use of the latest technology, continued education, and the best customer service available.
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