What’s the Question?
“9-1-1, Do you have an emergency?”
A large majority of the ambulance scenarios we handle start with that very question. But what about the questions you, as the provider on the scene, are asking?
Do you ask the probing questions that it takes to properly assess, treat and ultimately document your EMS scenario?
Let’s find out.
Field Questions
The questions we ask of our patients in the field go a long way toward nailing down a good assessment, effective treatment that will meet the patient’s needs and in the end provide you with enough information to prepare a complete Patient Care Report (PCR) that will support that you followed protocol and that will support medical necessity for billing.
So, what are the questions you should potentially be asking your patients in the field?
Demographics
Right off the bat, be sure that you know who your patient is. The obvious elements that are important include; name, address, Social Security number, date of birth, telephone number (including an area code).
Those questions are simple and probably can be asked by your partner while you’re assessing and beginning to treat.
Important questions to be included are…
How do you spell your name? What is your mailing address? Can you please provide me with your Social Security Number, date of birth and a phone number where you can be reached in case our billing office has some questions?
In addition, the other obvious questions to ask are questions about medications, allergies, past medical history, recent medical care such as doctor’s visits, diagnostic tests, screenings, etc.
Chief Complaint
The nice thing about this one is simply…you may not need to ask. Hopefully, someone…preferably the patient…will verbalize what they are experiencing that caused them to activate the 9-1-1 system.
But, if they don’t verbalize you’ll have to ask a good probing question to make them verbalize.
“Why did you call 9-1-1 today?” Sweet simple and to the point and it’s “the” core question when you think about it.
If that doesn’t solicit the desired response, maybe you can follow with a more direct approach using a phrase like “Tell me…”
“Tell me what you are feeling…” (It’s not really a question but can help effectively solicit a response.)
Establishing Baseline
Using the “tell me” approach to lead into your assessment line of questioning, we advocate that you always try to get the patient to tell you what’s different right now (remember effective documentation in a PCR is focused on the “right now”- not history, not overall diagnosis….but NOW.)
“So, tell me what’s different about how you feel today versus how you normally feel.”
Then, follow with the questions.
“Let me make sure I understand what you just said. Your headache progressively became worse not long after you awoke and are you telling me this is the worst head pain you’ve ever experienced? On a scale of 1-10, how bad is that pain in your head? Is your vision blurry? Do you have any numbness and/or tingling in your neck, face or arms?”
Not only are you effectively probing for what’s going on IN THE NOW but you are simultaneously collecting enough information about how the patient feels on a “normal” day versus whatever they are experiencing RIGHT NOW. The contrast you can create in your documentation between “normal” before your event and “not-so-normal” right now in the middle of the event can greatly help you establish a written word picture of the patient’s medical necessity.
Noting the deviation from the patient’s everyday baseline in your PCR will help you present supporting documentation to establish medical necessity.
The Q’s
Our discussion now turns on collecting the qualities and quantities within our PCR.
“How does that pain in your belly feel? Describe it for me.”
Or…
“What kind of pain are you having? Where is your pain primarily located? How long have you been experiencing this pain?”
You are specifically collecting Quality and Quantity which is important to your assessment and ultimately to the final step of documentation. One will hope that the patient responds with; “I have a really sharp, stabbing pain just below my ribs. It hurts so bad I can’t take a deep breath. The pain started about an hour ago and has just progressively gotten worse. I rate it at about a 9 on a 1-10 scale. It really hurts badly.
Of course this would be followed by your hands-on assessment and findings, etc. But, notice how you’ve been able to take the next step toward effectively assessing to find out what your treatment course of action will be. And…all of this leads to a very well-written, descriptive and detailed PCR in the end.
ICD-10 Application
As a regular blog reader, you have now realized that we are weaving an ICD-10 message into our weekly posts.
We have informed you that the success (or failure) of implementing successful ICD-10 code application beginning next October will be reliant on the amount of specific information provided in the PCR.
Be sure to get in the habit of asking probing questions to glean specific, detailed information about why the patient felt the need to use the EMS system today.
This applies to both 9-1-1 and routine runs.
Gone will be the days of documenting generalities. The questions you ask in the field, coupled with the numbers and the clinical side of the equation, will enable you to create and file an effective PCR at the end of the run.
Effective immediately, there are no “ill persons” documented without more specific detail. That detail will come from asking the right questions at the right time.
Communication
Everyone here enjoys communicating with our clients. This blog space is one example of how we effectively assist our clients to augment their PCR’s.
We’ll ask questions from time-to-time too in order to clarify any information that appears to be vague or not complete.
Asking questions is vital to the entire process.
Do you have a question about how we do what we do? If you’re a current client, initiate a Live Chat session, e-mail us or call us toll-free.
