There are certain common phrases seen in patient care report (PCR) narratives that do not provide any useful information describing the patient. A clear, complete and accurate patient description is critically important to fully document the clinical care and provide necessary information to make proper billing and reimbursement decisions. One of the most common “vague phrases” we see on a PCR is this: “The patient was transported in a position of comfort.” Unfortunately, this often-used phrase is meaningless because it does not objectively describe the position of the patient. For all we know, the patient could have been hanging in a harness upside down from the ceiling of the ambulance as their “position of comfort!”
It is always best to be clear and descriptive in your PCR documentation. Don’t leave a reader of your report guessing as to what you mean. For example, if the patient’s “position of comfort” was “lying supine on the stretcher with the torso elevated at a 45-degree angle,” and that is how the patient was transported, then it is best to document it using those words. That allows the reader of your PCR to mentally see the actual patient position.
The physical position of the patient upon arrival, how the patient was moved from that position to the stretcher, and the position of the patient during transport relate to the patient’s mobility status. Describing the patient’s positioning and mobility status are part of fully documenting the ongoing patient assessment. Both are essential information to document from a clinical standpoint — and it helps billing staff make a more accurate determination as to whether the services and transport were “medically necessary” under the reimbursement rules.
We’ve often heard that the goal of any PCR is to “paint a picture of the patient.” But what does that really mean? It means that the PCR will pass the “visualization test” — an independent reader of the PCR should be able to visualize in their own mind the very same patient that the EMS practitioner treated. One of the best ways to pass the visualization test is to avoid subjective statements. Subjective statements are your own opinions and conclusions. They are not accompanied by facts to support that conclusion. It is always best to be objective and stick to the facts: document what you see, hear, feel, and assess clearly and accurately. By documenting objectively, you avoid your statements being challenged, especially by attorneys questioning you in a court or deposition.
There are many other subjective and meaningless phrases that have crept into PCR documentation nationwide. Another example is “transported without incident.” What does this really mean? For all we know, it could mean that you were not involved in a major crash while en route to the hospital, the patient did not go into cardiac arrest or jump out of the ambulance. It is best to simply describe the patient’s physical and mental condition, response to treatment, changes in symptoms or pain levels, and other objective information observed during the time you spent caring for the patient and while en route to your destination.
As always, your PCR documentation must be honest, accurate, complete and timely. EMS practitioners should never make things up or misrepresent the patient’s actual physical condition when completing PCR documentation. Being descriptive in PCR documentation by avoiding vague phrases like “transported in position of comfort” and “transported without incident” will lead to more accurate and descriptive PCRs.