EMS Insider, Expert Advice

How to Write Good Patient Care Reports, Part 2: Avoiding Vague Terminology

Last month, we introduced the first of a five-part series on writing good patient care reports (PCRs), which focused on collecting patient information (See Full Article: How to Write Patient Care Reports Part 1 (of 5): Collecting Patient Information).
This month, for the second part of the series, we will focus on how to avoid vague terminology in PCRs.
In order to get claims paid, well-written patient care reports with complete and accurate information are imperative. 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 avoiding vague terminology in your PCRs?

Avoid any terminology that doesn’t give the reader a clear clinical picture of what the patient is experiencing. This should be especially followed when filling out PCRs for non-emergency transports.

  • Avoid vague terminology. Avoid using vague words or phrases such as “weakness,” “fall” or “transport for higher level of care.” The use of these terms doesn’t provide a clear clinical picture of the signs and symptoms for the patient at the time of transport. Try to be as descriptive and specific as you can. For example: “Patient started feeling weak beginning about one hour ago. Upon assessment, patient is unable to lift head and grip is weak. Patient is able to lift arms, but not able to leave arms up for extended period of time. When sitting patient up, patient is unable to maintain sitting position without assistance.”
  • Include the values of your assessment. Don’t simply state that the patient has high blood pressure. You need to document what your findings were when you assessed their blood pressure, including your assessment of their blood sugar level. For example: “During assessment, blood pressure was 210/100 in the right arm. This is high for patient’s normal blood pressure, which the patient states normally runs 140/85. Patient’s pulse is 80 and weak in the right wrist. Patient’s blood sugar was recorded as 95 with glucometer.”

Part three of this series will be discussed in the November edition of EMS Insider.

*Have any documentation questions? Email Grant Helferich, Omni EMS Billing’s documentation expert.

Grant Helferich is the EMS advisor/client trainer with Omni EMS Billing in Wichita, Kan. He has worked EMS for over 35 years.