Friday, January 5, 2018

Winter Flu Season- How to Document?

Holidays Behind Us…Enter Flu Season

We trust that you had a wonderful holiday season filled with many WARM memories (and we emphasize WARM!)

We’re back to our normal routine so let’s dig into a direct documentation topic…. How to document transports that are initiated either directly or indirectly due to the effects of influenza.

Winter and the Flu Bug

It’s winter. Especially for those clients we serve what is fast becoming one of the coldest most brutal winters in history, flu season ushers in a whole new set of treatment and transportation possibilities. Since this is a blog about all things ambulance billing, let’s take a minute to think about how we can effectively document when we transport persons affected by the flu bug.

Winter Flu Season- How to Document?

Do flu patients need an ambulance?

That’s a good question!

On the surface and in contrast to the many severe emergencies we all handle on a regular basis, we seem to think about influenza as being not so bad. But think again.

According to government’s Centers for Disease Control and Prevention, influenza activity increased sharply for the week of December 24th to 30th equating to a cumulative rate of 13.7 laboratory-confirmed influenza-association hospitalizations per 100,000 population.

Sadly, 26 pediatric deaths were recorded in the U.S. from just October 1st through December 31st. The CDC provides an annual estimate for adults as there are a myriad of complications that cannot be held directly related to flu as in pediatric patients, but the estimate for 2017 will see a potential high off 56,000 deaths due to flu occur out of a range of 9.2 million to 35.6 million influenza cases for the season.

So, the answer to our question is given the data...maybe.

The Facts

To get started with the documentation discussion, we remind all of you that we must describe the patient’s medical condition in sufficient detail to indicate why transportation by any other means other than an ambulance vehicle was contraindicated for your patient.
Your task is to describe the patient’s condition in full, including your assessments and the numbers and values derived from that assessment.

Since the older members of our patient population are often found by us in some kind of extended care facility, it is also important to document why the patient could not be adequately treated for influenza-associated signs and symptoms at the facility.

In short, was the trip reasonable in nature?

Documenting the Hands-On “Stuff”

So let’s brainstorm all the “stuff” we’ll see connected to flu patients and how we can document it all.

Respiratory Complications

Of course, with a fair amount of flu patients the influenza morphs into a respiratory situation sometimes resulting in the patient’s contracting pneumonia. For the oldest and the youngest of our patient population, this can be a life-threatening event.

So naturally we can think of our need to document…
  • Lung sounds (for patients in extended care facilities, we must also document how our treatment was needed beyond the treatment that cannot be provided at the facility)
  • Pulse-Oximeter Readings
  • Oxygen Delivery (delivery rates, delivery device, treatments- medications by inhalation, injection, infusion)
  • Need for suctioning
  • Use of positive pressure devices
  • Coughing and sputum observations

Dehydration and Fevers

If dehydration or even possible sepsis is a factor as an extension of the flu condition, then consider documenting things like…
  • Skin assessments – color, texture, feel (warm, hot, cold, etc.)
  • Severely elevated body temperature readings

Nausea/Vomiting/Diarrhea

What if nausea, vomiting and or diarrhea are part of your scenario? Then include findings such as…
  • Duration/Onset
  • Color and consistency of the solids and/or fluids expelled
  • Volume expelled compared to fluid intake as verbalized by the patient or someone in the know

Compromises and Secondary Systems Involvement

Does your patient have a chronic underlying condition that the flu now is exacerbating? If so, be sure to document those complications. There are times when we focus so much on the apparent that we can forget to include the spillover affect into other areas.

So, if there is any secondary compromise such as cardiac or general systems compromise, be sure to include those findings in your Patient Care Report.
  • What did the cardiac monitor tell you about your patient?
  • Was there any kind of neurological compromise that is negatively affecting your patient?
  • What did you do to counteract the negative secondary symptoms?

The Basics

Naturally, never forget the basics.

Always document…
  • Vital signs
  • GCS
  • Level of Conscious
  • Mental Status that varies from the patient’s baseline
  • Result of critical labs prior to EMS activation (however, negative values alone, minus signs and symptoms of a serious illness event will not constitute justification for payment)
  • Any associated pain (include a pain rating on a 1-10 scale, as you normally would do)

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