Tuesday, July 31, 2012

EMS Patient Care Report Writing | Documentation 101 | Part 1

Stick Figures vs. Art…
While God blessed me with the ability to effectively put my thoughts into words, He in no way provided me with more than a basic ability to draw things. My artistic level would be rated at "Kindergarten" and even then there's probably a few 4- or 5-year-olds out there that could whoop me in a good game of Pictionary. 

Stick figures are definitely a challenge and no one would ever call those crude images "art." I used to get sick just thinking about my next period's art class in school.

You may feel that way too, every time you sit down to write your Patient Care Report following the last ambulance run. "How can I paint a picture using words when using words isn’t necessarily my strongest skill? I hate writing! No one told me I had to do this. I thought it was all that cool stuff like driving the ambulance, playing with the siren and zapping people with defibrillators…not paperwork!"

Thanks for joining us!
Today marks the first in our Documentation 101 blog series.  Using the next several blog postings, we’ll be attempting to put together a few coaching blogs to help all of you become better EMS documenters. 

We hope you find this series helpful and we welcome your feedback and suggestions as we move forward.

A Picture in Words…
In one way or another, we all know how to tell a story.  I’ve sat around many a table, campfire, conference room table….wherever and heard some wildly entertaining and even educating stories.

From very ancient times, man has perfected the art of storytelling. So the ability to put our life’s experiences in words actually is very natural. But, for some reason translating those stories into words and applying them to paper causes our hands to sweat and our brows to furrow. 

But really it's quite natural. Close your eyes and pretend you’re telling the incoming shift about your last call. Can you picture it? Okay, then go ahead and start thinking of the words and you’re now ready to start documenting by putting those words into writing.

It Doesn’t Have to be a Best Seller
No one said your PCR has to be a literary masterpiece.  So relax.  But your PCR should make sense.  When you’re finished writing, ask yourself, "If someone picked up my PCR and read it for the first time would they be able to make sense of the EMS run I just concluded?"

If your answer is "Yes" then you’ve most likely just completed an adequate EMS Patient Care Report.  If your answer is "No" then read it over one more time and ask yourself, "If someone were reading this story to me, what is missing that wouldn’t allow me to understand what happened on that call?"

Chances are your second attempt will be much easier.

Don’t procrastinate…
Putting the subject off until tomorrow won't solve those unwritten PCR's that are piling up today.  Remember, each PCR potentially brings in dollars for your department to help pay your salary or incentive, buy new equipment and keep you riding in nice shiny ambulance vehicles. Writing a timely Patient Care Report also helps you to remember the incident before too much time lapses and insures that you protect yourself from mis-documenting a key element of the run.

Maybe you need some basic writing help?
There’s nothing wrong in admitting that you need help. You can even better yourself, personally, by learning to communicate in writing more effectively. There are tons of self-help tools on the Internet to assist you with writing and grammar skills. You may want to consider enrolling in a basic writing course at your local Community College or Adult Learning Center. Also, don't forget many ePCR programs incorporate tools such as spell and grammar checks and will even pick up on incomplete sentence structure, etc. Also, ask your supervisor, chief or a more experienced EMT, Paramedic or Health Professional to give you a hand if you’re stumped.

Enhanced to the Rescue!
We're not finished. As part of this documentation series, we'll include some specific steps to make you a better documenter. Make your goal to be the best documenter that your department has and you're well on your way to PCR writing success. But, in the meantime if all else fails and you still can't get your thoughts on the paper to complete an effective report, ask Enhanced for help.

Our qualified Certified Ambulance Coder© trained billing staff will be glad to assist you. Pick up the phone and call or drop one of us an e-mail. My e-mail address is chumphrey@enhancedms.com

Not an Enhanced client? 
No problem there. Check out our website right now at www.enhancedms.com and complete the "Get Started" section so we can connect.  We’d love to talk to you about the many features and how they can benefit your EMS Department!
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