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  1. Pro Bono: Six Tips for Writing High-Quality Patient Care Reports - Journal of Emergency Medical Services

    Subscribe | Newsletters | Advertise | Contact Us             Journal Supplements Subscribe Jobs Featured Jobs Search Jobs Post A Job Products Buyer's Guide Product Reviews Hot Products Hot Products Submissions Product Announcements Product Videos Webcasts White Papers Videos Ask the Expert Education & Training EMS 10 Interviews EMS Today Fitness JEMS Games Product Spotlight Home About Us Advertise Contact Us Our Team Authors Community Submit A Press Release News Patient Care Airway & Respiratory Cardiac & Resuscitation Trauma Administration & Leadership Communications & Dispatch Documentation & Patient Care Reporting Training Operations Ambulance & Vehicle Ops Equipment & Gear Rescue & Vehicle Extrication Major Incidents Mass Casualty Incidents Terrorism & Active Shooter Mobile Integrated Healthcare   Home About Us Advertise Contact Us Our Team Authors Community Submit A Press Release News Patient Care Airway & Respiratory Cardiac & Resuscitation Trauma Administration & Leadership Communications & Dispatch Documentation & Patient Care Reporting Training Operations Ambulance & Vehicle Ops Equipment & Gear Rescue & Vehicle Extrication Major Incidents Mass Casualty Incidents Terrorism & Active Shooter Mobile Integrated Healthcare Home Administration & Leadership Pro Bono: Six Tips for Writing High-Quality Patient Care Reports Pro Bono: Six Tips for Writing High-Quality Patient Care Reports Mon, Jan 18, 2016 By Doug Wolfberg , Steve Wirth, Esq., EMT-P Documentation is such an important aspect of what we do as EMS providers. It’s truly an essential part of patient care. The key piece of documentation is the patient care report (PCR) that becomes the clinical and legal record of the interaction with the patient. Unfortunately, some EMS providers don’t pay as much attention to documentation as they should, and we’re finding increasing numbers of claims denied by Medicare and other payers simply because the PCR didn’t provide enough information for the reviewers to determine if the transport met the requirements for reimbursement. It’s not the role of the field provider to determine if a particular transport meets medical necessity requirements—that should be done by Certified Ambulance Coders and billing professionals who know the requirements for each payer, which can vary significantly. But it is the EMS provider’s role to cover all the necessary bases and paint a complete and accurate picture of the patient’s condition and treatment provided at the scene and during transport. That means that for every patient encounter, high-quality clinical documentation is absolutely essential for patient care, reimbursement and risk management. Here are six tips for keeping your clinical documentation at the highest level: [Native Advertisement] Document the dispatch information.  The nature of the call at the time of dispatch may have a bearing on the level of response (i.e., ALS vs. BLS) and mode of response (i.e., emergency vs. non-emergency) and could also impact reimbursement. We see too many PCRs with no dispatch information or just general information like “sick person” or “unknown problem.” Call takers should work to get the most accurate information possible and convey that to the responding EMS providers so it can be documented on the PCR. Get correct demographic information.  This includes the exact address—including zip codes—of the patient point of pickup and the destination. This can impact mileage calculations and is essential to the billing process. Patient names should be spelled correctly, as one incorrect letter can delay payment claim submission. If time and the patient’s condition allows, try to obtain insurance information. Complete a narrative statement.  Nothing beats a clear, concise and descriptive narrative that describes the patient’s complaint, history, patient assessment, treatment and response to treatment, despite recent automation advances of electronic PCR software. Insurance claim reviewers are usually nurses who are used to reading nurse’s notes, histories and physicals, and other “narrative” documentation that describes the patient’s medical condition. The PCR narrative should follow a consistent format (e.g., CHART, SOAP) and be as objective as possible, avoiding subjective conclusions or opinions of the EMS provider that aren’t supported by facts. Spend time on improving your narrative writing skills, and if you rely on computer applications to create the narrative, make sure you review and edit it carefully. Document mileage accurately.  Most insurers will only pay “patient loaded mileage” and are demanding increasing detail, like documenting the loaded mileage to the tenth of a mile. Make sure you use accurate odometer readings. In some cases, web-based applications are permitted to document mileage, but onboard measurement of mileage is still preferred by many insurers. Both crew members should review and sign the PCR.  Just because you weren’t in the back of the ambulance with the patient doesn’t mean you had nothing to do with the patient. Any crew member who was involved in patient care in any way should legibly sign the PCR. Even though there may be a “primary” patient care provider, the other providers on the call should review the report before signing off. The printed names and certification levels/ credentials of all providers should appear below the signature. This is not only an excellent way to catch errors, correct inaccuracies and to make the PCR as complete and thorough as possible, but also makes sense from a quality assurance standpoint. Get the patient’s signature.  Most payers, including Medicare, require that the patient sign an “assignment of benefits form” assigning the payment for the ambulance service to your agency. The only time a patient representative should sign the form is when the patient is physically or mentally incapable of signing the form. Most ambulance transports, including 9-1-1 calls, aren’t life-threatening, and most patients are fully capable of signing—as long as they’re asked. The 30 seconds taken to obtain the patient’s signature in the back of the ambulance can help your EMS agency avoid unnecessary follow-up and improve the billing process. Above all, always be completely honest in patient care documentation and never misrepresent the patient’s actual condition or make things up. The true test of a well-documented PCR is if the person who’s reading the PCR can accurately visualize the patient as if the reader were standing alongside the provider during the call. Pro Bono was written by the attorneys at  Page, Wolfberg & Wirth , The National EMS Industry Law Firm. Visit the firm’s website at  www.pwwemslaw.com  or find them on Facebook, Twitter or LinkedIn. By Doug Wolfberg Douglas M. Wolfberg, Esq. - Doug Wolfberg is an EMS attorney and founding partner of Page, Wolfberg & Wirth, which represents EMS agencies throughout the United States.  A former EMT, Doug worked as a provider and administrator in numerous EMS systems over the decades. Doug also served as an EMS educator and instructor for many years.  Doug is a known as an engaging and humorous public speaker at EMS conferences throughout the United States. He is also a prolific author, having written books, articles and columns in many of the industry’s leading publications, and has been interviewed by national media outlets including National Public Radio and the Wall Street Journal on EMS issues. Doug is also a co-founder of the National Academy of Ambulance Compliance (NAAC). He is a JEMS editorial board member and also teaches healthcare law at the University of Pittsburgh and Commonwealth School of Law.  Doug can be reached at dwolfberg@pwwemslaw.com . Steve Wirth, Esq., EMT-P Stephen R. Wirth, Esq., EMT-P – Steve Wirth is a founding partner of Page, Wolfberg & Wirth, LLC, which represents EMS agencies throughout the United States, and a co-founder of NAAC, the National Academy of Ambulance Compliance.  In a distinguished public safety career that spans over four decades, Steve has worked in virtually every facet of EMS – as a firefighter, EMT, paramedic, flight paramedic, EMS instructor, fire officer, and EMS executive – and was one of central Pennsylvania’s first paramedics.  Steve is a dynamic and sought after speaker at EMS conferences nationwide, and has authored numerous articles and book chapters on a wide range of EMS leadership and EMS law topics.  He is a contributing writer for JEMS, (where he serves on the editorial board), EMS Insider, EMS1 and EMS World.  Steve teaches EMS law for the University of Pittsburgh EMS degree program and is also past Chair of the Panel of Commissioners for CAAS, the ambulance service accrediting body.  Steve can be reached at swirth@pwwemslaw.com . Sponsored Content is made possible by our sponsor; it does not necessarily reflect the views of our editorial staff. Journal Archives Prev 2016 2015 2014 2013 2012 2011 Next Feb 2016 Volume 41 Issue 2 Jan 2016 Volume 41 Issue 1 Prev 2016 2015 2014 2013 2012 2011 Next Copyright © 2016: PennWell Corporation, Tulsa, OK. All Rights Reserved. UTILITY Home About Us Contact Us Terms of Use Subscribe Advertise Submit a Press Release RSS Feeds Privacy Policy Topics News Patient Care Leadership Training Major Incidents Mobile Integrated Healthcare Operations Sections Authors Columns Community Jobs Journal Products Supplements Webcasts

    Magazine Articles

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    Mon, 18 Jan 2016

  2. King County, Wash., Implements Medical Control for EMTs - Journal of Emergency Medical Services

    Program offers safety net for patients, EMTs and the EMS system. 

    Magazine Articles

    Magazine Articles

    Fri, 15 Jan 2016

  3. Initial Findings in Strangulation Injury Aren't Indicative of Outcome - Journal of Emergency Medical Services

    Learn to assess for and recognize signs of unreported strangulation injuries that can potentially lead to delayed death. 

    Magazine Articles

    Magazine Articles

    Tue, 22 Dec 2015

  4. ZOLL Launches Major RescueNet ePCR Software Upgrade for Compliance with National Standards - Journal of Emergency Medical Services

    ZOLL Medical Corporation announced a major software upgrade for RescueNet ePCR, making it compliant with NEMSIS 3, the latest version of the national data collection and reporting standards.  

    Online Articles

    Online Articles

    Wed, 16 Dec 2015

  1. Pro Bono: Protect Yourself and Your Agency from Airway Liability - Journal of Emergency Medical Services

    Magazine Articles

    Magazine Articles

    Mon, 10 Aug 2015

  2. New Technologies Can Help Take Your QA/QI Program to the Next Level - Journal of Emergency Medical Services

    The Total Quality Management system links quality management efforts in the clinical, operations and billing arenas in order to comprehensively improve Richmond Ambulance Authority's service and efficiency.

    Magazine Articles

    Magazine Articles

    Mon, 6 Jul 2015

  3. CloudPCR Wins JEMS Hot Product 2015 - Journal of Emergency Medical Services

    CloudPCR launches new ePCR Trip Sheet software and immediately wins JEMS Hot Product 2015

    Online Articles

    Online Articles

    Tue, 23 Jun 2015

  4. CloudPCR Wins JEMS Hot Product 2015

    CloudPCR launches new ePCR Trip Sheet software and immediately wins JEMS Hot Product 2015

    Online Articles

    Online Articles

    Tue, 23 Jun 2015

  5. Hamilton Medical Introduces the T1 Transport Ventilator - Journal of Emergency Medical Services

    The Hamilton T1 ventilator features a compact, powerful design that increases the availability of appropriate modes of therapy for ventilated intensive care patients outside the hospital.

    Online Articles

    Online Articles

    Fri, 8 May 2015

  6. AMBARA Announces Spring Special - Journal of Emergency Medical Services

    How well do you know the effectiveness of your A/R?

    Online Articles

    Online Articles

    Thu, 7 May 2015

  7. Rethink the Way EMS Does Patient Care Reports - Journal of Emergency Medical Services

    EMS must let go of the idea prehospital care documentation is strictly about billing and creating a legally defensible record of events.

    Magazine Articles

    Magazine Articles

    Tue, 5 May 2015

  8. Modern Approaches to Health Information Exchange Will Improve Patient Outcomes and Decrease Cost - Journal of Emergency Medical Services

    Emerging methods for the exchange of health information show promise, from Regional Health Information Exchanges to Accountable Care Organizations and the future of Carequality.

    Article

    Article

    Fri, 1 May 2015

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