How Severe is Severe?
Part III
Welcome to Part III of our “Documentation as a Habit” series!
Two weeks ago we embarked on this series noting the necessity for EMS agencies to be intentional about Patient Care Report documentation review.
The series focused on explaining the coding considerations that every EMS provider must consider when completing the Patient Care Report following your EMS incident. We asked each of you to consider what the next person in line, the billing office, needs to do their job. We broke down the precise coding considerations in six parts…
- Location
- Severity
- Mechanism
- Causation
- Relationship
- Stages
This week we’ll take a look at severity.
Detail
When looking at severity, the key is documenting sufficient detail in the Patient Care Report (PCR). It’s really about putting numbers along with descriptions that go beyond the obvious.
In this day of precise coding models, CERT reviews, auditing and covering the bases for legal ramifications; we need to be sure that we are describing the illnesses and injuries our patients are experiencing using clear clinical documentation.
Clinical
The connotation best to think of when it comes to describing what clear clinical documentation looks like is to think of what the word clinical means in this context.
Webster’s dictionary points to three considerations when referring to the word clinical.
Clinical Auditing
For the EMS world, the word clinical, central to our discussion of severity, has three applications. The first is in the context of auditing.
Here clinical means measurement and evaluation of patients using some information gathering mechanism with a view towards outcomes.
Boiled down, it’s questioning.
The first step toward gaining details about the severity of a patient’s condition, be it injury or illness, is our survey of the patient’s condition complete with hands-on observation and asking key questions. When a patient tells you they have severe abdominal pain, we should follow with a hands-on palpation of the abdomen and drill-down questions to discover a pain rating, description of the pain in the patient’s own words (dull, sharp, stabbing, aching…) and, as discussed last week, location (RLQ, LLQ, RUQ, LUQ.)
Of course, what we hear and find we document.
Clinical Pattern
The word clinical takes yet another bend when we consider that we are documenting the patient’s pattern leading up to activating the EMS system.
Here we begin collecting and documenting signs and symptoms presented by the patient to you, the EMS healthcare professional.
It’s a complete no-brainer that all signs and symptoms collected at the scene must be documented in great detail in the Patient Care Report. Not only do they lead you to a treatment protocol and its execution but it leads you to documenting that same treatment protocol as activated in the field.
Clinical Picture
The word “sketch” is used in the dictionary to describe this segment of our discussion.
Think of your Patient Care Report as a sketch in words, or as the Centers for Medicare and Medicaid Services (CMS) like to put it…paint a picture in words regarding your scenario. Your PCR should include a discussion of all facets of the patient’s illness or injury that includes specific references to the onset, continuation and effect that the patient’s illness or injury is having on them in such severity (or lack thereof, as sometimes is the case) that they or someone near to them felt the need to call 9-1-1 or request a routine transport.
Quality and Quantity
The combined use of quality words and numeric values, as much from the patient’s own verbalization, is key to adequately labeling severity in your PCR.
Quiz the patient sufficiently to solicit how they feel about their injury or illness and hopefully they will articulate most of your PCR to you.
“When I fell, I immediately felt a sharp stabbing pain in my neck.”
“Can you describe the pain for me on a 1-10 scale please?”
“Oh, it’s a 10 for sure!”
Bam! You now have a direct patient interaction that you can document to describe the severity of your patient’s illness or injury. Likewise, get in the habit of using a combination of quality and quantity words derived from your assessment.
(Sample PCR narrative) – “Upon arrival we noted the patient had a large, approximately 6 inch open wound to her right lower extremity with bone exposed and severe bleeding totaling approximately 1 liter of volume pooled on the floor beneath her. The blood was bright red in color and was spurting from the wound.”
You’re on your way to providing your billing office with a fantastic PCR that fully explains your scenario.
Great job!
