Friday, March 21, 2014

Excellent Patient Care Provider? Prove It with Your Documentation!

You’re the Best!
In our opinion, everyone who’s ever taken a class and has become an EMS First Responder is the best!

Who's Awesome? You're Awesome!
The question echoed by a very wise instructor one time, replays itself in the memory banks…

“If not for you, then who?”

Down through the years I hope you’ve reminded yourself of that over and over again.

YOU are awesome for doing what you do, regardless of your practice level. Every day you stand in the balance between life and death and we applaud you for it!

If you didn’t write it…
Speaking of memorable phrases, recall this one…

“If you didn’t write it, you didn’t do it.”

Following your run, if your documentation doesn’t include every single detail of what happened to the patient that caused them to activate the 9-1-1 system, of course including everything you did to stand in the gap, then it’s as good as if it didn’t happen.

All your worthy efforts are as good as nothing if they aren’t properly recorded in your PCR.

So what’s up?
If all this is true and we learn all this basically on “day one,” then why are so many of us so reluctant to tell the story in words about our EMS scenario following the run?

It’s time to prove you’re the best.

So what’s up?

Why are we so reluctant to write a complete, concise and detailed PCR?

We just don’t get it until we have to get it and then it’s sometimes too late.

I understand if the “newbies” in the industry don’t get it. They’re still learning.

But those of us with experience and years of EMS under your belts that buck writing our PCR’s timely and precisely just baffle us! We know what can happen when we’re misrepresented. And…if we don’t want to protect ourselves, at least we owe it to those new people to set a good example of how to complete the run by preparing adequate documentation.

Delayed charting, inaccurate charting, incomplete charting is simply unacceptable in today’s EMS culture.

Lose the ‘Tude!
Folks, it’s time to get over it.

As we think back over our collective careers here in the billing office and out in the field, we are reminded that we have more tools to effectively and efficiently prepare an effective PCR today than at any time in modern EMS history.

Three-line narrative sections and bubble/dot sheets on clunky NCR carbon forms are way a thing of the past. Many of you now have mobile devices to use to write your PCR on-the-fly.

So, our message to you is…

Lose the ‘Tude!

Get over yourself and drop the chip-on-your-shoulder attitude about charting. Solemnly swear, as of today, to complete your PCR immediately after every run using all the tools provided to effectively “paint a picture” in words about your EMS run.

Billing and Beyond
We’ve been telling you all about the new ICD-10 diagnosis coding initiative that is now just a little over six months away.

Your billing office will be pressing more than ever for the most concise detail you can provide when preparing your PCR following your incident. It takes a staggering amount of dollars to run your EMS system, even if you’re department is still one of the lucky ones to remain mostly volunteer.

If the money doesn’t come in, the rigs don’t roll. As a field provider, you play the biggest role in effectively kicking off the billing cycle for each run you are involved in. The information you collect while treating and transporting your patient which then is eventually placed in your PCR, will set the tone for payment of the claim that is sent out to the insurance company or other payer source.

But it goes beyond billing.

Remember your chart is the only legal, written record of that EMS healthcare incident. Your PCR is actually a legal health record document which can be reviewed, subpoenaed, criticized, critiqued…whatever.

It may be your butt on the line someday attempting to defend something you did (or didn’t do) on an incident. If you haven’t effectively written your PCR in such a manner that there is no question about what transpired in the scenario and if the actions you took, as the care provider, were appropriate, adequate and followed accepted protocol…you could wind up in a heap of trouble.

There’s Help!
Enhanced clients are given access to a wealth of information.

This blog space is just one example. Using the versatile Enhanced PulsePoint™ client portal complete with the Enhanced App for mobile devices, our education pieces are available at your fingertips.

Now it’s up to you.

If your organization isn’t an Enhanced client and you don’t have access to these helps…call us today. Our Business Development Manager, Chuck Humphrey, is standing-by via e-mail to chumphrey@enhancedms.com or he’s available by phone at (800) 369-7544, Extension 108. 
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