Administration and Leadership, Columns, Documentation & Patient Care Reporting

Pro Bono: Six Tips for Writing High-Quality Patient Care Reports

Issue 2 and Volume 41.

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:

  1. 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.
  2. 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.
  3. 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.
  4. 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.
  5. 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.
  6. 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.