How to Write Good Patient Care Reports Part 3

How to Write Good Patient Care Reports

Part 3 (of 5): Justifying Medical Interventions

by Grant Helferich

Last month, we shared the second part of a 5-part series on writing good patient care reports (PCRs), which focused on avoiding vague terminology (See Full Article: October 2016 newsletter).

This month we will be focusing on justifying medical interventions documented in your PCRs.

Encourage your staff or colleagues to use these criteria as guidelines to writing complete and accurate PCRs that reduce the chance of insurance denials.

Criterion 2: Are you justifying the medical interventions reported in your PCRs?

It's important to fully explain the reasons why you provided the medical interventions documented in your PCR. Don't think of it as just providing more detailed information to insurance companies to reduce denials of claims. You are also providing continued care for the patient, as the receiving facility will get a complete picture on what care was provided to the patient and the outcomes of that care.

☑ Provide a clinical reason for using an ECG monitor
.

Always explain in clinical terms why you used a particular medical intervention during a transport. For example, stating that you applied an ECG monitor due to medical protocol is not a clinical reason for using the ECG monitor. Explain the clinical reasons or why the patient would benefit from each medical intervention.

Example: ECG monitor was applied to patient to rule out any cardiac conditions associated with the patient's onset of weakness.

☑ Include information about the outcome of the medical
intervention.

If there was a change in the patient's condition, document the change and how you assessed it.

Example: ECG impression using a 4 lead was RSR without ectopics. Heart rate is 80.

Stay tuned for Part 4...

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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