EMS Patient Care Report Writing | Documentation 101 | Part 6 – Signs and Symptoms
The “Best” of the Ambulance Billing Services blog
Two years ago we put together a “Documentation 101” series of eleven educational blogs, covering what we determined to be the fine points of writing an effective Patient Care Report. Since then, the series has been read by dozens of patient care providers all across the Country. The series has been used for crew training and as a point of reference across our clients and friends in the EMS industry.
This week, we’ll be focusing on the importance of recording and documenting the patient’s Signs and Symptoms.
By the numbers…
The great thing about documenting Signs and Symptoms is that it all has a lot to do with the numbers. In this case, you are recording your findings which are obtained by the skills you’ve developed for assessing things about the patient that, by and large, you can measure.
It’s basic but important stuff! So let’s break it down into bite-sized parts.
Cardiac
You are obviously going to assess and record the patient’s pulse rate. Along with the numbers-based beats per minute or rate, you will also be recording the rhythm. Think of all the good, descriptive words you can use just about a pulse rate, such as rapid, irregular, regular, bounding, racing, strong, weak and many more.
Of course there’s a slight difference between ALS and BLS providers on how you will assess and record these numbers, with ALS providers pulling off additional information from a cardiac monitor to quantify and qualify the type of rhythm and a heart rate in addition to a pulse rate. Add the results of a 12-lead EKG in the field along with copies and prints of actual “strips” and you have provided a full picture of the patient’s cardiac condition at the time of your interaction with the patient.
Respiratory
Record and document present respiratory findings. Simple assessment and details of the patient’s breaths per minute and the quality of those breaths noting respiration qualities using words such as shallow, rapid, labored, normal, etc. You can describe actual breathing conditions such as wheezing, asthmatic, agonal and others.
Lung sounds come to play here as you will be assessing those sounds with the help of a stethoscope and noting if there are rales or rhonchi. I’ve seen people use words like “crackles” or even “bubbling” to describe the sounds they assess.
In addition, you will be noting left- versus right-sided sounds or the absence of sounds and also recording if there is any abnormal activity in any one of the four quadrants of the lungs (left upper, left lower, right upper, left upper or using abbreviations LUQ, RLQ, etc.)
You most likely will also have a measuring device at your disposal, using and recording the percentage of oxygen in the patient’s blood with the help of a Pulse Oximeter Machine (a.k.a. PulseOx). Be sure to note the reading each time. Also be sure to note changes in those readings, especially when those readings change to denote a negative change in condition which may require an upgrade in care (BLS to ALS) and/or a change in treatments (changing oxygen delivery rates and/or devices like moving a patient from 2 lpm via nasal cannula to 15 lpm via non-rebreather mask.)
In more serious situations, such as cardiac arrest you most likely will be recording capnography readings as well, which is another quantitative device/tool to work with resulting in a documented reading within your PCR.
Scoring
Another very important quantitative resource we use and record from the field is the Glasgow Coma Scale. The GSC is a simple means of documenting the patient’s overall status using the three criteria that makes up the GCS.
With many of the elements that we record and document in our PCR’s we walk a thin line between objective and subjective. In the case of recording a GCS, the reading is very objective in how we approach and determine the final scoring. There is little doubt left to the reader (or the auditor) regarding the patient’s level of consciousness and overall well-being if the GCS is recorded properly and supported throughout the chart by other observations as part of your assessment.
You may also use trauma scoring as part of your documentation. In a burn scenario, you are quantitating the percentage of the body covered by burns when you using the Rule of Nines in your PCR. Of course with burns you would also be labeling the burns by the type and quality by documenting the degree of the burn (1st, 2nd, or 3rd).
You will also note the level of consciousness of a person by noting the level of conscious and alertness from four vantage points. Common to PCR’s is the abbreviation “CAOx4” or Conscious, Alert and Oriented times (X) four (4) meaning the patient is awake and alert on all four levels- to person, place, time and events.
Other Readings and Recordings
I think by now you get the point that the sky’s the limit on the things you can record using numbers or quantitative type readings.
You can record if the patient’s pupils are equal, non-equal, reactive, non-reactive, pinpoint, fixed, mid-position or maybe use the common abbreviation, PERL. You may wish to record your assessment of capillary refill by assessing the change in color of the nail bed and how fast they refill.
Such methods as recording your findings after using the Cincinnati Stroke Scale methods to assess a patient presenting with possible CVA findings are very important in painting the overall picture.
We have so many tools available to us. Once the recording device or the method is used, be sure you document those findings. It will be most difficult for an auditor or an evaluator of any PCR to dispute findings that are completely objective and quantifiable.
And, to close out this section, it is most important to record 1-10 scale pain ratings as verbalized by the patient during your assessment. Whenever pain is present, be sure to note the patient’s rating of pain by asking the patient to apply a number based on a 1-10 scale.
ALS Providers Have Additional Findings and Items to Record
In the ALS world, ALS providers have additional resources of measurable values to record and paint the picture regarding the patient’s condition.
Consider how you can quantify a diabetic emergency by simply providing a reading from the glucose monitor and recording the results in quantities of milligrams per deciliter (mg/dl).
Of course, ALS providers will be expected to record quantities and times when medications were pushed, IV’s were initiated, drip and flow rates and a myriad of other quantifiable levels and amounts that exist in the ALS world. Simple things like recording a patient’s weight, may be a factor later when recording the amount of a drug that is administered and used.
Symptoms- effectively using descriptive words
With the quantitative signs come the sometimes not-so-quantitative symptoms. Here’s where you are recording what the patient is telling you and you are finding by way of your assessments.
We talked last week extensively about the patient’s Chief Complaint, symptoms extend from determining the chief complaint and then extend through your probing to learn what the patient or the patient’s representative(s) can tell you the patient was experiencing prior to activating the EMS system and what he/she presents with right now.
This can be a wide range of many things using descriptive and specific words such as “descriptives , “ including severe, moderate, light, aggravated, mild, exacerbated…..we can come up with a million of them if we sit and think hard.
What is the patient doing in your presence? Is he/she vomiting, fainting, gasping, leaning, etc. How about using descriptive words like flaccid, discolored, pale, ashen? Again, if we take that trail and we can think of many good words to describe what the patient’s symptoms are and how they are presenting to us both in assessing the symptoms and describing our observations and findings as a result of noting those symptoms.
Be sure to apply time frames in your explanations of the patient’s symptoms, for example; “The patient has been experiencing nausea and vomiting since 2300 hours last night,” or “Patient first experienced chest pain approximately one hour ago and describes the pain as an 8 on a 1-10 scale.”
Important Stuff!
Phew! Somehow we think we could write a book, alone, on the subject of recording Signs and Symptoms. But we think by now we’ve given you enough to think about the next time you sit down to type out another PCR. Other than recording your treatment, which we’ll tackle in a future post, recording Signs and Symptoms is vital to writing and preparing your Patient Care Report. It’s important to paint the overall picture in words regarding your EMS incident.
Communications
In countless communications from CMS (Medicare and Medicaid) we read over and over the directions they are giving which focus on “painting a picture” in words of the EMS incident you are documenting.
Directions we are reading, direct providers of pre-hospital care to provide clear clinical documentation using objective, detailed, precise findings and observations. The push for greater record keeping, including the explosion of electronic health record initiatives (ePCR’s) in EMS, further provides avenues for us that we must follow in satisfying the requirements as presented to us by insurance payers and most notably from CMS.
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You’re well on your way to mastering the techniques necessary to author effective Patient Care Reports while helping to support your billing office, along the way.
We hope the picture has begun to make sense for you as we piece this puzzle of effective Patient Care Report writing together in easily understandable and manageable parts. Feel free to print these blog postings and share with your friends.
