How to Write Good Patient Care Reports, Part 1: Collecting Patient Information

An often underrepresented skill that EMS staff need to work on is writing detailed patient care reports (PCRs) that provide a clear clinical picture of the patient’s needs. While providing the best care for the patient is important, it’s vital that this care be accurately reported.

Why should this be your concern? For many EMS services, the bulk of revenue comes from insurance reimbursements. An incomplete or inaccurate PCR may result in a denial of reimbursement for services from the insurance company or even a demand for a refund after payment has already been made. Continued patient care can also depend on well written PCRs, as receiving facilities may use these as a guide as to what treatment patients have already received and future treatment plans.

This series will focus on five criteria EMS staff need to review while writing PCRs. Each month we will focus on one new criterion.

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 1: Are you collecting all necessary patient information?

While completing each PCR, report all the following information:

  • Detailed dispatch information: This information validates the reason and level of response. For example: Unit 1 responded to report of chest pain with dizziness.”
  • Patient demographic information: Make sure to include the patient’s full name, current address, phone number and date of birth in order to bill the insurance company and receive reimbursement for services.
  • Patient insurance information: Collect all insurance information for billing at one time by obtaining copies of insurance cards. Having a scanner on board your rig is a sound investment for this purpose. Obtain copies of the patient’s insurance card from the receiving facility if you are unable to collect it during transport.
  • Chief complaint: What medical conditions did the patient indicate upon arrival? When did the symptoms start? For example: “62-year-old male states onset of chest pain with dizziness approximately 15 minutes before calling 9-1-1. Patient states he was mowing the yard when he had the onset of chest pain.”
  • Detailed primary and secondary assessment information: What signs and symptoms did the patient communicate during your assessment? What were your clinical findings? For example: “Patient indicates no pain on palpation during examination of sternal and chest areas. Patient states chest pain radiates to right arm and denies difficulty breathing at this time. Patient’s skin is cool, pale and moist to touch. Pulse is equal on both wrists at 85, and is irregular.”
  • Detailed information about medical procedures performed and their outcome: For example: “IV established in left hand with 18 gauge rate TKO. Patient received three aspirin (324 mg) P.O., nitro sublingual. Patient indicates no pain relief after nitro. ECG established shows sinus rhythm as irregular with a rate of 86 and multifocal PVCs.”
  • Your impression: Using the information obtained, what do you think is clinically going on with the patient? For example: “Chest pain cardiac related, cardiac dysrhythmia, dizziness.”

Part two of this series will be discussed in the October 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.

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