EMS Patient Care Report Writing | Documentation 101 | Patient Demographics

EMS Patient Care Report Writing | Documentation 101 | Patient Demographics

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.

For the next few weeks we’re going to pull a few of the posts from that series to provide you with a “refresher” course. Feel free to print and share with your fellow EMS providers and as always we welcome your comments and input.

Who is the patient- Spelling is important!

Before we go any further in this series, it’s important to be reminded that we must properly identify our patient before we can even begin to tap out a Patient Care Report.  The patient is the very subject of the report. If we can’t properly identify the patient as part of the report, it pretty much voids anything else that’s written in the report.

Name spelling is critical!

Get in the habit of asking your patient or their representative this question, “How do you spell your name?” This is especially critical with reference to last names.

This is a case where “hooked on phonics” just won’t do. In this day and age of electronic health records and computerized claims for billing, the exact match of a name in the hospital database or in the insurance records will make all the difference in pulling up and matching key data connected to the patient you just transported.

You also don’t get a pass on first names. For example, computer databases will fail to match the written name “Christa” if your patient’s name is spelled “Krysta”. Just because you may pronounce both names the same doesn’t mean those two very unique spellings will match in any electronic patient database.

Numbers…

Vital information, such as the patient’s Social Security Number, Date of Birth, Telephone Number (including area codes) and Insurance Numbers are very important to the billing process. Since we are writing these blogs from the billing office perspective, this information is very important for effective billing of the claim.

There are a number of online tools that your billing office uses every day to verify and seek vital information about patients. These numbers also help keep the billing database clean by not allowing similar names (for example, Joe versus Joseph) to be entered for the same patient.

In addition, obtaining this information helps not only the billing office contact and interact with the patient but also provides the receiving facility with information that allows the facility staff to call up information such as past medical history, medications, allergies and also to possibly even contact family and next-of-kin.

Addresses…

You most likely are aware of the dispatch address for your patient. But, do you know his/her mailing address?

If you collect the mailing address for the patient your billing office will have no problem working with your patient to resolve any billing/claim issues. Especially for those of you who operate in a rural setting, you may find whole communities where residents pick up their mail at a Post Office Box instead of receiving door-to-door delivery. Providing the dispatch address location will not prove one bit helpful when mailing communication out to the patient. Vital patient communication after the call often comes in the form of a bill, letters, forms to sign and other important mailings.

In addition, please remember to properly identify the location where you pick up the patient. Is the origin of the call a scene (corner of Pig Road and Cow Road) and remember to record the zip code of the point of origin for your trip. Please be specific in the Patient Care Report about recording where you picked up your patient. Was the point of pick-up a skilled nursing facility, the church, the local high school, a hospital or maybe a personal care home or assisted living facility?  Be sure to correctly identify the location type and address of the point of pick-up.

But it’s all on the hospital face sheet!

Indeed, the information you provide may be right there on the hospital/ER face sheet or you may call it a hospital demographics sheet. But that written hospital record is only as good as the hospital’s updating process.

I’ve found that all the latest and greatest information may not be listed in hospital databases. A growing number of facilities are omitting information out of “fear” of the HIPAA rules and for other security reasons.

Also, keep in mind that auto insurance and worker’s compensation information will probably not be included on those hospital forms, so gathering that information if your patient has been involved in a motor vehicle crash or in a work-related scenario is vital to the resolution of the claim.

Including patient demographic information in your Patient Care Report is part of completing the run and is vital for many reasons.