Wednesday, October 24, 2012

EMS Patient Care Report Writing | Documentation 101 | Part 10 - Miscellaneous

Welcome to Part 10, the final installment in our twelve-week 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
    Part 6: Signs and Symptoms
    Part 7: Mileage and Odometer Readings
    Part 8: Treatment
    Part 9: Medical Necessity
    Part 10: Miscellaneous


Wrapping Up
If you’ve been with us from the start we hope you've acquired some valuable skills for authoring an effective Patient Care Report.

In our final week, we'll look at some "miscellaneous" items to be aware of when putting together your PCR. 

Chronology
For most of us that use an ePCR program, recording the chronology of events for our incident happens in the section known as the flow chart.

The flow chart allows the author of the PCR to record events in the order they occurred and apply a time stamp to those events. This is the common area of the PCR where vital signs are recorded along with numeric values for oxygen saturation, Glascow Coma Scale numbers and the like. Most ePCR programs have an area to record notes about what was taking place at various times in the incident, as well.

This area is especially important to make notations should the patient’s condition worsen as well as documentation about changes in treatments and responses. Cardiac rhythm and rate notations as well as quality and quantity of respirations would also be noted in this area.

The end result is the reader can quickly review a time line of events, so to speak, to gain a picture of the “flow” of the EMS incident being described.

Outside Assistance

We remind you to always include notations about any outside assistance that may have been provided during your incident. If anyone other than you or your partner provided patient care of any sort either before your arrival or during the incident make sure to make a notation in your PCR of the identity of the person, level of training (or lack of training, such as a citizen bystander), care provided either witnessed or un-witnessed by your and any outcomes of that care (negative or positive).

Transport Incidents.  Be Specific
Be careful when documenting the events that occur during transport to be specific in nature.  Many times we read PCR’s that make general statements such as “…transported without incident.”  While you may understand what this means to you, we caution about vague statements that can be interpreted by the reader to potentially mean something else.

We highly recommend that you be specific when documenting. Include descriptions of conversations with the patient. Include documentation of outcomes, treatments provided, interventions and procedures undertaken during transport. Especially note when the patient provides updates about how they feel, better or worse, and the steps you have taken to mitigate any new developments.

Be specific!

Transfer of Care
There are times when you must transfer care to another individual. Of course, protocol will dictate that you turn over care to another healthcare provided who is equally or higher trained in most cases.  Be sure to document who you turned over care to when doing so in the field and what their level of training was.

For example, “Patient care was transferred to flight paramedic J. Smith who assumed patient care at the scene and prepared patient for transport via air medical.

In addition to in-the-field transfer notations, we also suggest that you include a notation regarding the transfer of patient care to facility personnel upon the completion of your incident. Upon arrival at the hospital, be sure to note the name of the facility staff member that you provided report to and the location of the patient within the destination facility. Noting that the patient was in the direct care of facility personnel and the disposition of the patient upon exiting can be very helpful in describing how the incident concluded.

Transferring/Moving the Patient
Extremely important on the billing side of the equation are notations documenting the movement of the patient. This includes all ways that the patient was moved from one position to another.

At the scene of the incident it is important to note how the patient was moved from the position you found him/her to the position for transport. Did the patient walk to the litter, stand and pivot; was the patient sheet lifted, positioned on a long spine board or any other means?

In addition, upon arrival at the transportation destination how was the patient moved from the ambulance stretcher to the next position. Be sure to be specific regarding these patient movements.  For example, “Upon arrival at XYZ Hospital ER, patient was moved from the ambulance stretcher to ER bed in Room 9 using a four-person, sheet lift method with the aid of this crew and ER staff.  Transfer was completed successfully, side rails put in place to protect patient and patient was left in the care of ER staff upon completion of the incident.

Times
We close out this discussion by reminding you to be sure to include the times of the incident in your PCR. Typically, these times are provided by the 9-1-1 or Communications/Dispatch center and include the time the incident was received, time dispatched, time of ambulance response, time of arrival (could include first-responders arriving on scene to initiate patient care prior to ambulance arrival), time of access to patient, time en route to the destination, time of arrival at destination and time of incident conclusion. Of course, depending on the incident there may be other times that are important and need to be noted such as, for example, time of extrication where entrapment is involved, time of arrival of air medical, down time for patients in arrest, etc.

Conclusion

Well there you have it. Twelve weeks of a comprehensive discussion concerning writing effective Patient Care Reports. Now it’s up to you to use our recommendations to improve on your documentation skills. Have you arrived? We’re sure not. Even the most seasoned veteran provider can improve on documentation skills. It’s a work in progress.

Of course, it doesn’t end here. We’ll continue to blog about pieces of the puzzle in the days ahead in order to assist you in preparing the most comprehensive documentation you can produce. Your success contributes to our success as the billing contractor and in the end everyone benefits! 

Thanks for following our blog
Thanks for taking the time to follow our blog. 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 has done to help you become a better Patient Care Report writer.  E-mail me with any suggestions you may have for topics we can cover to assist you in the future.

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