EMS Lawline: Three Documentation Best Practices to Reduce Risk and Lower the Patient’s Financial Vulnerability

Steve Wirth, Esq., EMT-P

“I didn’t get into EMS to do paperwork!” is a common cry we hear when it comes to completing the patient care report (PCR). However, as we know, patient care documentation is not just important–it is truly an essential part of patient care. When it comes right down to it, the PCR is also the “best evidence” of what the emergency medical services (EMS) practitioners did or did not do while caring for the patient. And, if you are an EMS practitioner on a witness stand, your credibility is based on two things: how you come across in your personal testimony and the quality of your PCR. It’s just you and your PCR on the witness stand! Hopefully, you both can come across credible and professional in front of a jury.

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Complete Documentation: Important for the EMS Agency

From a risk management viewpoint, the PCR is used as evidence to prove (or disprove) negligence, abandonment, wrongful death, false or fraudulent claims, and a myriad of other legal claims that can be brought by a patient against the care providers and the EMS agency. The PCR is also used by Medicare and insurance company auditors to determine if your agency has met the requirements to be properly paid by them for the level of service you provided. For example, the “medical necessity” of an ambulance transport is determined primarily from what is found (or not found) on the PCR.

If the clinical information documented is incomplete, vague, or does not paint an accurate picture of the patient’s condition at the time of transport, then an auditor may find that medical necessity was not met, and the claim would not be payable. This means the EMS agency’s remaining option may be to bill the patient directly for the ambulance service as a noncovered service.

Complete Documentation: Important for the Patient

Which leads us to the patient’s viewpoint. EMS practitioners are entrusted with the care of medically vulnerable patients. From the patient’s standpoint, an incomplete or inadequate PCR may also leave the patient financially vulnerable; the patient can literally get stuck with the bill. Inadequate documentation can leave the patient financially responsible to pay bills that insurance would have otherwise paid for medically necessary services.

So, not only is a patient medically vulnerable when we care for them, but our own inadequacies in documentation can leave the patient financially vulnerable as well. This can exacerbate the suffering of the patient, and that is not good patient care.
You may have heard the story from 2018 about the woman in Boston who suffered a serious leg injury after she became trapped on a train platform. She gained national attention because she pleaded with bystanders not to call an ambulance for her. “Do you know how much ambulance cost?” she said to them as she cried and begged them not to call an ambulance. (Boston Globe, July 2, 2018). Patients should not have to worry about the costs when they are suffering physically!

Today’s high cost of ambulance service requires that we do the best possible job we can in adequately documenting the care and services we provide; it is a professional responsibility. High-quality patient care documentation will help maximize the likelihood that Medicare and other payers will pay the claim, thus reducing risk to the EMS agency as well as reducing financial vulnerability for the patient.

The following are three fundamental “best practices” to follow when completing patient care documentation to help reduce risk for the agency and minimize the patient’s financial vulnerability:

Document Completely

EMS practitioners must ensure that all relevant information is captured and documented honestly and completely. The EMS practitioner should never falsify documentation or misrepresent a fact or an observation. Determining what is relevant requires professional judgment and is based on your assessment of the patient, your experience, and your documentation skills.

A PCR that captures all relevant information helps paint a clear picture of the patient’s condition at the time of service. This means that another person reviewing the PCR after the call can read that PCR and actually “visualize” in his own mind the patient cared for by EMS. Help paint this picture by using descriptive words and relying on a logical and chronological format for completing documentation.

Documenting completely would also include obtaining all necessary signatures including signatures of the EMS practitioners who participate in the care of the patient, the patient or responsible party if the patient cannot sign, and the signature of a receiving facility representative who received the patient.

Document Accurately

This requires honesty in all aspects of documentation. EMS practitioners must be accurate in documenting all assessment and treatment information. This includes accuracy in documenting the information that is conveyed to you from the patient and others as well as full and accurate descriptions of the patient’s physical, mental, and medical condition.

Accuracy is also important in the description of all treatments provided including identification of the drug or treatment provided, dosages, routes of administration, identity of the practitioner who provided the treatment, and the effect of any treatment on the patient.

Document Timely

EMS practitioners must comply with all state EMS requirements for timely completion and submission of PCRs. Some states have specific time frames in which EMS agencies must submit completed PCRs to the receiving facility, often within 24 hours of the service.

However, it is also essential that all necessary patient information be communicated to the receiving facility at the time of transfer of patient care, even if the final PCR is not completed. Some EMS systems use field notes or other types of preliminary reports to provide to the facility until the completed PCR is available. Ideally, the PCR should be completed as soon as possible after the service has been provided. Today’s electronic PCR programs allow for improved efficiency; in many cases, the PCR can be completed before the crew gets back to the station.

The bottom line is that accurate, complete and timely completion of PCRs is a legal and ethical responsibility of the EMS practitioner. Treating this essential responsibility in a serious manner and as an essential part of patient care will help reduce legal risk for yourself and your EMS agency and help reduce the likelihood that the patient will be financially vulnerable for the services that we provide.

Steve Wirth is a founding partner of Page, Wolfberg & Wirth, LLC. and has been involved in all facets of EMS from field provider to EMS attorney in a career that spans over 40 years. He has authored or co-authored hundreds of articles, blogs, and book chapters on a wide range of EMS leadership, reimbursement, risk management, compliance, and workplace law topics.  He can be reached at:  swirth@pwwemslaw.com    

For over 20 years, PWW has been the nation’s leading EMS industry law firm. PWW attorneys and consultants have decades of hands-on experience providing EMS, managing ambulance services and advising public, private and nonprofit clients across the U.S. PWW helps EMS agencies with reimbursement, compliance, HR, privacy and business issues, and provides training on documentation, liability, leadership, reimbursement and more. Visit the firm’s website at www.pwwemslaw.com.  This article is not intended as legal advice.

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