Documentation & Patient Care Reporting

Top 10 Documentation Mistakes Ambulance Providers Make – and Supervisors Overlook

Steve Wirth, Esq., EMT-P, one of the nation’s leading EMS attorneys and a founding partner of Page, Wolfberg & Wirth, gave a very dynamic presentation on improving documentation at the annual meeting of the American Ambulance Assocation (AAA) on Saturday, Sept. 8, 2018, at the MGM Grand Hotel Conference Center in Las Vegas.

Wirth carefully dissected the documentation process to show how quality patient care reports (PCRs) support the clinical, operational, and reimbursement aspects of your ambulance operation. He illustrated how some services can’t bring these three elements together and are on a continuous “treadmill of mediocrity” when it comes to truly taking their documentation to the next level.

He drilled down to the core of the most critical documentation mistakes field providers make – and supervisors overlook and covered specific strategies to improve performance in these key areas of your operation.

The First Challenge: Fighting Apathy & Laziness!

Wirth started by saying that personnel have to learn to be accountable, accept the fact that EMS is a “collaborative” process, and that we are ultimately accountable to the patient and the public; and an essential aspect of patient care.


For additional information on best practices to improving documentation, see the gallery that accompanies this article.

Mistake #1: Poor Spelling, Bad Grammar & Use of Improper Acronyms and Abbreviation.

Crews need to pay attention to these important areas because lawyers and reimbursement officials will use inaccuracies and errors against you.

Mistake #2: Narrative Does Not “Paint a Picture” of the Patient’s True Condition

Noting that “the quality of your documentation reflects the quality of your service,” Wirth pointed out that the PCR and narrative (content and the way it’s written) tells the story of your care.

He stressed that the PCR is the provider’s “substituted memory” and “should pass the ‘visualization test’ (i.e., can you see the patient when you read the narrative?)”

He also noted that you must present/note a detailed description of the patient’s condition at the time of the transport! 

Mistake #3: Making Subjective Conclusions or Stating “Opinions”

You must document objectively, not subjectively, what you observe.

Use good charts/processes to keep you on track:

O.P.Q.R.S.T.

  • Onset
  • Provocation
  • Quality
  • Radiation
  • Severity
  • Time

D/R.A.A.T.T.

  • Dispatch
  • Response
  • Arrival
  • Assessment
  • Treatment
  • Transport

C.H.A.R.T.

  • C = Chief Complaint
  • H = History (Past & Present)
  • A = Assessment
  • R = Rx or Treatment
  • T = Transport and conditition enroute

Mistake #4: Internal Inconsistencies

There can’t be inconsistencies in the narrative. For example, if you check off both “normal” and “amputation” on an anatomical chart, or describe it differently in your narrative – you will raise red flags with reviewers, payors or lawyers.

Mistake #5: Improper Addendums or Corrections

Wirth noted that it’s the provider’s duty to make accurate, honest added addendums/notations to make sure your PCRs/narratives are accurate.

First and foremost, any corrections must be true, accurate and honest!

Never change documentation just to get a claim paid. However, you need enough documentation to allow a determination to be made as to whether it should be made, and at what level of service.

If you miss something important and think of it later, attach an addendum sheet and state why you are attaching it. (E.g., “We didn’t know this information at the time of transport,” or, “On the original report, we failed to note that oxygen was administered.”)

Remember that it’s OK to make documentation mistakes; but you must correct them ASAP after you realize them.

Mistake #6: Failure to Adequately Address “Medical Necessity” and “Levels of Service”

Direct citation from 42 CFR 410.40(d):

“Medicare covers ambulance service only if they are furnished to a beneficiary whose medical condition is such that other means of transportation are contraindicated.”

Direct citation from Medicare Claims Processing Manual, Chapter 15

“Ambulance providers must maintain adequate documentation of the patient’s condition, other on-scene information, and details of the transport (e.g., medications administered, changes in the patient’s condition, and miles traveled, all of which may be subject to medical review by the Medicare contractor or other oversight authority. Medicare contractors will rely on medical record documentation to justify coverage.”

Make sure your crews know that, as a public service:

  1. Not every transport will get billed to Medicare or insurance for payment; and
  2. We may transport and may not ALWAYS BE ABLE TO BILL MEDICARE – and in those cases the patient or another payer may be responsible.

Mistake #7: Failure to Document the REASON for the Transport and Interventions

Patient’s condition must meet medical necessity requirements to bill Medicare (must go by ambulance) and the transport itself must be “reasonable” (i.e., must need to go in the first place).

Good to note in your narrative: “On arrival we found the patient in a hospital bed in the living room.” (This shows beyond doubt that the patient was bed-confined.)

Mistake #8: Failure to Obtain Necessary Signatures

Signatures verify that the ambulance services were actually provided:

  1. You need the patient or a representative for assignment of benefits (AOB);
  2. Those who order patient services (PCS for non-emergency transports); and
  3. Those who perform health services – crew members’ signature on the PCR. (Note: Although not required, Wirth recommends that both crew members sign whenever possible.)

You can obtain a sample ambulance signature form on the Page, Wolfbert and Wirth website.

If P.U.T.S (Patient Unable to Sign) and R.U.T.S. (Representative is Unavailable or Unwilling To Sign) you need:

  1. A statement documented from the crew – verifying P.U.T.S. (and why) & R.U.T.S.; and
  2. The signature of a receiving facility representative OR other SECONDARY documentation.

Note: Signatures can be obtained electronically with field data collection devices.

Mistake #9: Failure to Record Patient Loaded Miles

  1. Medicare and many other payers only pay loaded miles to the closest appropriate facility.
  2. Record odometer readings (with tenths) at the point of pickup and at the patient destination.
  3. GPS devices will continue to be acceptable (citation from 75 FR 73477).

Mistake #10: Second Guessing & Making Improper Assumptions

Don’t do it!  Don’t be judgmental. Be accurate and act in the patient’s best interest. Be descriptive, but not judgmental (e.g. “patient was drunk” or “patient did not need to go to the hospital”).

Mistake  #11 (Bonus!): Failure to Conduct “Patient-Specific Conversations”

Crew should do a quick (“Plus/Delta”) debrief when the go to posting or get back to their station after the call. It’s a great opportunity to discuss:

  1. What worked well;
  2. What would/should we change in the future?; and
  3. Realize that you failed to note something(s) important on the PCR, which gives you the opportunity to append the PCR.