EMS Insider, Expert Advice

The Dos & Don’ts of Documentation

DON’T copy information.

Write each transport as if this is the first time you have seen or treated this patient. Do not copy information, especially your narrative, from a previous report. Each patient care report must be a stand-alone report.

DON’T use vague terms.

Patient is experiencing “pain” or has “weakness.” These are insufficient terms and should be avoided. Your impression should be detailed, walking through signs and symptoms shown before and during the transport. If the patient or family states the patient is weak, do an assessment and document what limitations are associated with the weakness. Can they not hold their head up? Unable to hold their arms out? Will the patient fall out of chair if left in sitting position without restraints?

DON’T use P.U.T.S. in place of the patient’s signature.

The Centers for Medicare and Medicaid Services (CMS) has indicated there should be very few occurrences in which a patient is unable to sign the patient care report such as cardiac arrest, stroke or a dementia. If there is a true medical reason the patient is unable to sign the patient care report, you must document all the medical reasons for this. CMS has also provided instructions in the Ambulance Billing Manual for those few cases the patient is unable to sign such as having an authorized family member sign for the patient.

DO support medical necessity.

By definition, medical necessity proves why transportation by any other means is contraindicated for the patient. In order for insurance to pay, medical necessity must be proven within the documentation and should include the primary impression, chief complaint and all corresponding treatment to the patient. Note that CMS has stated that the diagnosis of a disease or illness may not be enough without corroborating evidence/statements to support medical necessity for ambulance transport.

DO be specific.

Include in your patient care report a detailed assessment on every transport as well as the findings of your assessment. Include Glascow coma scale, skin conditions, mental status, pain level, ect. Be very specific in documenting all the signs and symptoms of the patient’s chief complaint.

DO be truthful.

Make sure your documentation is truthful. It is not in your best interest to develop a list of terms or symptoms to use to get the transport paid. Your patient care report is a medical legal document. Using false statements in your report to support medical necessity can result in a prosecution in the court of law.

DO document treatment results.

Remember to note all treatments in your narrative. Explain the situation, symptoms, actions taken, and the effects of treatment. If a medication is administered to the patient, include in your report whether there was a positive, negative or no reaction. 

medical documentation for EMS