“My Belly Hurts!”
Could it be a protruding alien creature?
You’re on-call today. The pager trips and the dispatcher announces that the EMS system has been activated by a 57 year old male patient complaining of abdominal pain.
Just because it’s Halloween your mind races to visions of aliens protruding from the patient’s abdomen in a ghoulish presentation of blood and guts, right?
Nah! Probably not!
Realistically, as you drive toward the patient’s residence you run down the list of possibilities of what this patient could be experiencing to manifest itself in the pain the patient is reportedly experiencing.
There are a million different possibilities for what the patient is suffering. Your job is to assess, decide on the best course of action, transport and report to the next person in the patient care loop.
Then, finish the loop by writing the best Patient Care Report you can.
It’s a pain!
A few weeks ago we blogged about documenting pain, in general. Check back to that blog and go over the key elements of pain documentation. Those rules apply here, for sure.
Your focus today is on a patient complaining of belly pain. You find the patient alert and oriented but in a notable amount of distress.
How do you know he’s distressed?
Well, you find the patient guarding his abdomen, sitting in a bent-over position with even a slight amount of associated respiratory distress.
Your assessment and your documentation both start at this point.
Be sure to paint the picture in words about what you find upon arrival. Surely you would note the guarding of the abdomen, any moaning or complaining of pain that the patient verbalizes. The fact that you find him bent over in a chair with practically his head positioned between his knees is a good thing to document and a good thing to note as you assess and begin to treat.
Also, what will you be doing to mitigate the associated difficulty breathing? Probably at least some initial low-flow oxygen, coming in at a 2lpm flow via a nasal cannula unless the breathing is so compromised that it’s life threatening.
Again, be sure to document this in your Patient Care Report. Always remember to note any associated signs and symptoms.
Numbers
Pain is one of those symptoms that you can apply a number value to. Do it.
Mark this in your mental documentation notes right now… NEVER DOCUMENT A PAIN CALL WITHOUT USING A 1-10 SCALE PAIN RATING!
So, like a recent patient we encountered in the field just a few weeks ago told us when we asked how bad the pain was, he quickly without thought replied with a quick; It’s about a “20”!!!
Translation? It really, really hurts! (That patient wound up to have a bleeder in his belly and was in the operating room the very next day following our transporting him to the hospital).
So what if the patient tells you the number is “off the charts”- literally and figuratively. Note it. Document it and attribute the quote back to the patient in your PCR.
In addition, if you are suspecting a “hot belly” never miss taking multiple blood pressures for comparison sake (if transport time allows you to do so). Pulse ox reading for this particular patient with the association shortness of breath and a sugar check is probably in order too.
Hands-On Documentation
By now we hope you have moved into palpating the abdomen. This lends to a really good and thorough assessment and provides some observations from the hands-on portion that will help you put this scenario into some detail in words.
As you assess the abdomen by palpation, you will be noting in your PCR documentation if there is tenderness, additional guarding other than the obvious and where the severity of the pain is manifesting (one of the four quadrants). Always note where the pain is centered if it can be pinpointed to any one of the quadrants and here abbreviations are acceptable (RLQ, LLQ, RUQ, LUQ).
For example, you document…
“Upon palpation, I find the patient to be complaining primarily of a pain rating of “10” on a 1-10 scale with the pain most notable via tenderness in the left lower quadrant (LLQ) of the abdomen.”
If you find rigidity and/or distension of the abdomen when you palpate, you’ll definitely want to document that too. Be sure to check for, and of course document, any findings of what may feel like a mass or lesion presenting itself, especially if the mass is pulsatile in nature. We all know that this finding certainly could be the sign of a very serious or life-threatening emergency such as an aneurysm or other circulatory system compromise with a possibility of internal hemorrhage. Your detailed documentation of this finding can be a life-saving piece of information to pass along to the receiving facility care-givers.
Trauma is a possibility? Document it!
It’s always good to ask the patient if he/she suffered any trauma of any type to the abdominal area. Should that be the case, then that opens up a whole realm of additional possibilities that need to be documented.
What was the nature of the trauma? Where did the injury take place? What was the mechanism of the injury? And the list goes on and on.
Assessing, treating by protocol, transporting with noted precautions and finally documenting all the associated signs, symptoms, injuries and outcomes should be detailed, complete and paint the necessary picture in words for your event.
ALS Providers
Beyond basic assessment documentation, ALS providers, be sure to take this one-step further and document your interventions and protocol goals as they were met.
Of course, as usual, document any IV therapy with resulting fluid introduction, medications infused and other assessments such as cardiac monitor readings. All should be noted including the appropriate pertinent negatives and assessment findings.
And… ALS or BLS, it is certainly important to make notation of any discharge or bleeding of any abnormal type especially when associated with abdominal pain.
ICD-10 Considerations
As promised in our last week’s blog, at this time we basically use the ICD-9 code for Pain, Abdomen Generalized. That actually maps to a single ICD-10 code. However, drill deeper and we found that when we got into the issue of distension where there is simply one code now for suspected abdominal pain related to gas pains, that particular code mapped to four different distinct codes in the ICD-10 scenario including codes for Gaseous Abdominal Distension, Gas Pain, Eructation and even Flatulence (the R14. Series of codes ranging from R14.0 to R14.3.)
Take note at how specific we all will need to be with our PCR documentation next year when ICD-10 hits the scene so your billing office can pick the most appropriate diagnosis code to submit a claim for payment.
The last time?
When’s the last time you read a blog about belly pain? You just did because we cover all the bases at Enhanced.
We hope you learned something valuable to augment your PCR documentation today just by reading this space.
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