By Grant Helferich
Detailed documentation plays an important role in ambulance transport reimbursement. If your organization has been plagued with poorly written patient care reports the organization could be in poor financial health. This is especially important with the implementation of ICD-10 coding. Here is a checklist of questions EMS providers should answer before submitting a patient care report (PCR):
- Are your descriptions detailed enough?
- Are the abbreviations you used appropriate and professional?
- Is your PCR free of grammar and spelling errors?
- Is the chief complaint correct?
- Is your impression specific enough?
- Are all other details in order?
1. Check descriptions
Upon the completion of every ambulance call, a PCR documents 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 specific, informative, free of ambiguity and negligence. But yet, after all extensive training, the best some medics can do in the detailed assessment is to write “patient has pain to the arm.”
- Which arm is the patient having pain?
- 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 radial pulses present during your assessment?
There are many fine details that should be documented in the PCR. “Patient has pain in the arm” will simply not do.
2. Review abbreviations
I have observed a steady degradation of the communication skills of my friends, family and coworkers since the introduction of instant digital communication. We have reduced the English language to acronyms, blurbs and gibberish. This type of language does 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. Here are four abbreviations I have seen in PCRs that should never be used:
- PUTS — Patient unable to sign.
- TMB — Too many birthdays.
- FLB’s — Those funny-looking beats in an ECG.
- HTK — Higher than a kite.
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 PCR says “patient fainted and her eyes rolled around the room.” Though this is a humorous example, 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. For example, the trauma surgeon should have a good understanding of the mechanism of injury that brought the patient to the hospital from reading your report.
4. Assess your chief complaint description
An area of the PCR that is frequently misused is the chief complaint which should explain why you were called to the scene or why the patient is being treated. Chief complaint is not the cause of the injury. For example, a chief complaint is pain to the right lower arm, not the fact that the patient has fallen off a ladder. Using the patient’s own words is an appropriate practice if they describe the symptoms of their chief complaint.
5. Review your patient impressions
An impression encompasses the reasons for patient treatment. Trauma and fall are too vague to be used as impressions. Include the body areas or symptoms that are being treated. In other words, what treatment protocol is being followed?
If you are following a head injury protocol, and your assessment indicates a possible head injury, this should be included in your impression. Multi-system trauma injuries bring additional challenges, but if multi-body systems are involved, they all should be included in your impression of the patient.
6. Check the final details of the PCR
With the implementation of a more detailed ICD-10 coding, the patient’s past medical history and medications are important to note. Avoid writing “history on file.” Document the patient’s history completely. Hospital providers use this information if the history could affect the patient’s outcome.
Another important aspect to document is the outcome of your treatments. Some PCRs have a standard text box that indicates improved, but in your narrative, you should document how the treatment improved the patient’s condition.
About the author
Grant Helferich is the EMS Advisor/Client Trainer 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. Helferich has worked as an EMT, EMT-I, MICT, Field Supervisor, Flight Paramedic, Cardiovascular Specialist, Assistant Director, and Director of EMS.
This article, originally published on February 15, 2016, has been updated.