EMS Insider, Expert Advice

How to Write Good Patient Care Reports, Part 3: Justify Medical Interventions

Last month, we shared the second part of a five-part series on writing good patient care reports (PCRs), focusing on avoiding vague terminology (See full article: How to Write Good Patient Care Reports Part 2: Avoiding Vague Terminology).

This month we focus on justifying the medical interventions documented in your PCRs. 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 3: Are you justifying the medical interventions reported in your PCRs?

It’s important to fully explain the reasons why you provided the medical interventions documented in your PCR. Don’t think of it as just providing detailed information to insurance companies to reduce denials of claims. You are also providing continued care for the patient, as the receiving facility gets a complete picture on what care was provided to the patient and the outcomes of that care.

  • Provide a clinical reason for performing a medical procedure. Always explain in clinical terms why you used a particular medical intervention during a transport. For example, stating that you applied an ECG monitor due to medical protocol is not a clinical reason for using it. Explain the clinical reasons, or why the patient would benefit from each medical intervention. For example: “ECG monitor was applied to patient to rule out any cardiac conditions associated with the patient’s onset of weakness.”
  • Include information about the outcome of the medical intervention. If there was a change in the patient’s condition, document the change and how you assessed it. For example: “ECG impression using a 4 lead is RSR without ectopics. Heart rate is 80.” 

 

Part four of this series will be discussed in the December 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.