Friday, November 21, 2014

Grading the Documentation Pop Quiz-Scenario 2

Wrapping it up…
We wrap up the Our Documentation Quiz, 3-Part series this week with our discussion of “Scenario 2.” If you missed the first week’s post that outlines Scenario 2, use the blog home page to drill down to our post two weeks ago.

In the past we presented two hypothetical scenarios and then we asked a few questions to make our readers think how they potentially would handle documenting the scenarios in their Patient Care Reports (PCR’s) as if they were the EMS provider on the incident.

Documentation Quiz Results
Scenario 2
Here is the scenario we presented as part of our quiz.

Our patient is a 57 year old female who fell from a standing position and has pain in her left leg and is unable to get up due to the pain, suspecting a possible fracture.

You, as the EMS provider, arrive on the scene to find the patient lying on the floor in a puddle of water on the floor. The patient tells you that she was shopping for produce and slipped and fell due to the water which was there while a maintenance person was mopping up the remains of a smashed watermelon that someone had dropped.

The store manager stands next to the patient with a clipboard in hand asking the patient for her personal information while expressing concern for the patient’s condition.

Q1- While treating your patient, what questions should you be asking and what information should you be gathering about the patient’s injuries and the mechanism that caused the patient to fall?

A-  There’s no right or wrong answer here, but really this question is answered by simple “Assessment 101.” Certainly with this type of scenario you will be doing a complete head-to-toe hands-on assessment in an attempt to determine any and all injuries. Th full assessment and the results of that assessment should be documented. Never hesitate to say exactly what you did, when and how you did it. Document that you palpated potential injury areas. Document if the patient complained of pain or you detected a potential injury area by documenting if you felt any abnormal areas such as asymmetrical areas, any angulation indicating potential fractures, crepitus, etc. You should note skin color (or discoloration as the case may be), swelling, lacerations, bruising, bleeding, etc.

Q1a- What values should be documented?

A1a- In this case the most obvious value is to document the patient’s pain rating since the scenario involves a fall and includes a complaint of pain. All EMS PCR documentation should include a pain rating if pain is a patient complaint. By simply asking the patient where the pain severity falls on a 1-10 pain rating scale, you can cover some ground in your PCR helping to paint the medical necessity picture for your patient. Other values would be assessed depending on the outcome of your head-to-toe assessment.

Q1b- Think about and list all the parts of your scenario…

A1b- We challenged you to think about how you would document four areas…Treatment, Packaging, Patient Extrication and “Other”. With this in mind, it goes without saying (we think) that any hands-on treatment you provide should be documented in specific detail. It is also important that you document exactly how you packaged the patient and how you moved the patient. We strongly suggest that you always document the patient’s condition before packaging, during packaging, how you packaged the patient and then how you finally moved the patient on the scene and from the scene to the ambulance. Other important information would be to document any pertinent facts you have derived from your assessment and treatment of the patient at each critical point in your scenario including upon arrival, when treating, while packaging, throughout extrication and during transport.

Q2- Is it important to collect health insurance information for this scenario?

A2- We always suggest that EMS providers attempt to collect all insurance information for the patient. In this case, the patient fell but the injury seems to be caused by a hazardous physical condition that existed on the floor in the supermarket aisle. If you answered “Yes” that is the more appropriate answer, however even if you answered “No” you’re not incorrect because we will deduce that you were thinking that this is a liability situation and not a medical situation. However, why not collect all of the information? You may need it later! (We admit this was a bit of a “trick” question- we hope it made you think!) Other than health information, certainly you would continue to gather any and all additional information to identify your patient.

Q3- Can you benefit from the store manager’s presence?

A3- Since this scenario strongly hints that the store may be responsible to pay for your patient’s injuries within the confines of their liability insurance coverage, we believe the appropriate answer is “Yes.” . The manager’s presence can potentially be very helpful to you as you can collect information from the manager regarding, at the very least, who to contact in the event that ultimately the billing office determines that this scenario calls for billing to the store’s liability insurance. If we were the provider and if time allowed, we would be collecting no less than the store manager’s name and contact information so the billing office can contact that person later for further information. The store manager may also be helpful in relating the details contributing to the mechanism of injury.

Hope you had fun!
We hope you had fun with this little “Pop Quiz” exercise. Feel free to use this as a teaching tool to help your providers brush up on their documentation skills. Contact us, if we can help!

The Ambulance Billing Services blog is an educational tool provided by Enhanced Management Services, Inc. Enhanced Management Services, Inc is a full-service, all-EMS third-party billing contractor with Fire/EMS client throughout the United States. To learn more about the EMS billing services provided, visit our website at and click on the “Get Started” button.
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