Last month, we shared the third part of a five-part series on writing good patient care reports (PCRs), which focused on justifying medical interventions (See Full Article: How to Write Good Patient Care Reports Part 3: Justifying Medical Interventions).
This month we focus on providing a complete, accurate and detailed narrative 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 4: Are you providing a detailed narrative with complete information in your PCRs?
While writing your narrative for each PCR, report all the following information:
Detailed explanation of medical necessity: Your narrative should be detailed and provide a clear explanation for why the patient needed to be transported by ambulance. Include what the medical reasons were that prevented the patient from being transported by any other means. For example: “Patient transported by EMS for recent onset of weakness and hypertension. Patient unable to maintain sitting position without assistance, patient unable to lift head. Unsafe for patient to sit in car or wheelchair due to risk of falling. Medical monitoring of patient’s condition required for the safety of the patient. Secondary exam completed on patient en route to hospital.”
Detailed information about symptoms: Include information on what the patient was doing prior to the symptoms, time of onset, if there was anything the patient attempted to improve the symptoms, and what made the symptoms worse. For example: “Patient had been mowing the yard prior to onset of chest pain. Patient stated he stopped mowing and came into the house and rested without relief. 9-1-1 was called approximately 15 minutes after onset of symptoms. Patient does not have a cardiac history and does not have nitro to self-administer.”
Location of symptoms: Be detailed when documenting the location of the symptoms and include laterality (on which side of the body the symptoms are located). For example: “Patient states pain to right upper arm on movement and palpation. Patient rates level of pain an 8 on a 1-10 pain scale.”
The last part of this series will be discussed in the January edition of EMS Insider.
Grant Helferich is the EMS advisor/client trainer with Omni EMS Billing in Wichita, Kan. He has worked EMS for over 35 years.