Thursday, September 20, 2012

EMS Patient Care Report Writing | Documentation 101 | Part 5 - Arrived on Scene and Chief Complaint

Welcome to Part 5 of our continuing blog series “EMS Patient Care Reporting Writing/Documentation 101”.

    Part 1: EMS Patient Care Report Writing
    Part 2: Field Notes
    Part 3: Patient Demographics
    Part 4a: Nature of Dispatch - Emergency vs. Non-Emergency
    Part 4b: Level of Service
    Part 4c: Dispatch - BLS Level of Service & Routine Transports
    Part 5: Arrived on Scene and Chief Complaint

This is the seventh installment in the series. Thanks for allowing us to take a break last week to honor our fallen brothers and sisters in memory of the 9/11 terror attacks. 

Now it’s time to get back on topic.

In this post we’ll be dealing with the importance of recording what you find upon arrival and then we’ll tackle the all-important Chief Complaint documentation.

Arrived on Scene to Find…
Over the course of three blog topics we exhaustively covered recording the dispatch on the call. We know by now that you have a good grasp on that very important concept. Documenting what you arrive on scene to actually find is somewhat an extension of that whole dispatch concept and yet quite different.

In this case you are basically documenting if you find what you were dispatched for or, as we all know, find what we didn’t expect. We love our dispatchers. Our hats come off to the fine men and women that sit in that busy, stress-filled room, answer those frantic calls for help and calmly take note of the problem and get us out and where we need to be on the street. Without those fine professionals our jobs as providers would be completely impossible.

But sometimes what they are told isn’t exactly what’s going on.  That’s why documenting what you actually arrive to find is very important. Because, if what you find is different from what you were dispatched for, it not only changes your scope and plan of action, but it may also require that you call in additional resources to help you properly cover the medical emergency or trauma that you are presented with.

Recording the steps you have taken in the field to cover what you find will protect you legally and also, most definitely, will seal the level of billing for the call based on how you react to the situation you are assigned to.

Chief Complaint

Next in line is documenting your chief complaint. Once you have arrived and you find what you are presented with (emergency or non-emergency) you then must determine what the patient or patient’s representatives are telling you as to why they activated the EMS system.

The Foundation
When you think about it, your patient’s Chief Complaint, drives everything you do after this. Your assessment, your treatment, where and how you transport and finally after everything is said and done how you document.

Too often, providers miss on noting the correct Chief Complaint. By missing it, it then leads their documentation in the rest of the Patient Care Report down a trail that never really speaks to the true nature of what motivated the patient and/or his representatives to activate the EMS system.

Properly recording the Chief Complaint is like building a house on a firm foundation.  If the foundation isn’t set correctly, in time the house will collapse.  The same is true for your documentation.  If you do not nail the Chief Complaint then not only are you probably not going to be able to adequately care for your patient but you will, by extension, miss the mark when you type up your Patient Care Report.

Example…
You’re dispatched for a respiratory distress emergency. You respond and find that your patient is a chronic COPD sufferer having been diagnosed with emphysema for many years. Now the patient activated the 9-1-1 system today for respiratory difficulty, but when the billing office obtains the trip sheet, the biller notes that the provider has listed emphysema as the chief complaint and continues to explain, in great detail, the patient’s long past medical history.

What’s wrong with that? 

What did the patient complain of upon arrival? That’s right….not emphysema but “I can’t breathe!”  That’s the Chief Complaint! Maybe you even list it as just that in quotations or at least dyspnea or SOB (shortness of breath). That’s your Chief Complaint not emphysema.

What’s Going on with your Patient RIGHT NOW?!

Your Patient Care Report should always document what the current status of the patient is. Past medical history certainly needs to be noted and how it plays a role. But, focus less on that angle and more on the patient’s current condition that caused them to use an ambulance.

Remember, we must provide documentation regarding why the patient could not safely be transported by any other means to the intended destination. You must answer, why transportation by any other means is contraindicated for this patient, RIGHT NOW!

Same for Non-Emergencies/Routines
The same principle applies to non-emergency or routine transports. This sometimes presents a challenge for the EMS provider on the call. Our task is to document the patient’s condition and again answer the question why this patient is required to go by ambulance and not any other transportation option.

You are documenting the current condition of the patient that prohibits him/her from being transported safely and with no detriment to his/her overall health and well-being by any other mode of transportation.

Especially remember to be clear of the patient’s chief complaint (or lack thereof, if that is the case) for return trips after treatment, such as discharges from hospitals back to origin. Many providers will use the same Chief Complaint that the patient had for the initial trip (probably an emergency) to the ER for the return from the ER. But think about it; if the patient is returning after being successfully treated in the ER then does that patient have the same Chief Complaint that he/she did before being treated?

In most cases no.

So, now you must assess your patient and gather information with regard to their need for an ambulance to return from treatment and that first involves coming up with a Chief Complaint to set the tone for your documentation.

Your Turn
You’ve been with us now for seven weeks. Thanks for hanging in there.

You’re well on your way to mastering the techniques necessary to author effective Patient Care Reports while helping to support your billing office, along the way.

We hope the picture has begun to make sense for you as we piece this puzzle of effective Patient Care Report writing together in easily understandable and manageable parts. Feel free to print these blog postings and share with your friends. If you have any questions, be sure to e-mail your contact here at Enhanced. My e-mail address is chumphrey@enhancedms.com.

Let me know what this series is doing to help you become a better Patient Care Report writer. E-mail me with any suggestions you may have for topics we can cover as part of this series.

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We’re just waiting for you to contact us.  Visit our website at www.enhancedms.com and click on the “Get  Started” button. Submit your contact information to us and we’ll be in touch to talk with you about the many ambulance billing features we offer to benefit you as a potential client!

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