Flu-Like Symptoms- How to Document?
Spring?
Spring has sprung…or has it?
Given that we just experienced a major east coast winter snow storm just two weeks ago with New England about to get hammered again, it appears that Mother Nature is a bit confused.
The Flu!
Because Mother Nature is confused we see a lingering flu season. Flu season ushers in a whole new set of treatment and transportation possibilities. Since this is a blog about all things ambulance billing, let’s take a minute to think about how we can effectively document when we transport persons affected by the flu bug.
Do flu patients need an ambulance?
That’s a good question!
On the surface and in contrast to the many severe emergencies we all handle on a regular basis, we seem to think about influenza as being not so bad.
But think again.
The United States Centers for Disease Control and Prevention (CDC) cites that flu-associated yearly deaths in the United States have historically ranged from a low of about 3,000 to a high of about 49,000 people.
The CDC has this to say about influenza in the United States.
“Many seasonal flu-related deaths occur one or two weeks after a person’s initial infection, either because the person may develop a secondary bacterial co-infection (such as bacterial pneumonia) or because seasonal influenza can aggravate an existing chronic illness (such as congestive heart failure or chronic obstructive pulmonary disease).”
Flu-related serious illness may be even far greater than the government is able to track.
The Facts
Now that we’ve established that there may be those patients who really need an ambulance due to the effects of the flu, let’s brainstorm how we should be documenting these transports to paint the picture in words about our scenario in order to justify being reimbursed.
Describe the patient’s medical condition in sufficient detail in your Patient Care Rerpot to indicate why transportation by any other means other than an ambulance vehicle was contraindicated for your patient.
Be sure to describe the patient’s condition in full, including your assessments and the numbers and values derived from that assessment. In the back of your mind, you must always direct your documentation to describe if the patient would or would not have suffered negatively by being transported by any other vehicle other than an ambulance.
Since the older members of our patient population are often found by us in some kind of extended care facility, it is also important to document why the patient could not be adequately treated for influenza-associated signs and symptoms at the facility.
In short, was the trip reasonable in nature?
Documenting the Hands-On “Stuff”
Brainstorm with us all the “stuff” we’ll see connected to flu patients and how we can document it all.
Respiratory Complications
Because influenza often morphs into a respiratory scenario we can think of our need to document…
- Lung sounds
- Pulse-Oximeter Readings
- Oxygen Delivery (delivery rates, delivery device, treatments- medications by inhalation, injection, infusion)
- Need for suctioning
- Use of positive pressure devices
- Coughing and sputum observations
Dehydration and Fevers
If dehydration or even possible sepsis is a factor as an extension of the flu condition, then consider documenting things like…
- Skin assessments – color, texture, feel (warm, hot, cold, etc.)
- Severely elevated body temperature readings
Nausea/Vomiting/Diarrhea
What if nausea, vomiting and or diarrhea are part of your scenario? Then include findings such as…
- Duration/Onset
- Color and consistency of the solids and/or fluids expelled
- Volume expelled compared to fluid intake as verbalized by the patient or healthcare provider.
Compromises and Secondary Systems Involvement
Does your patient have a chronic underlying condition that the flu now is exacerbating? If so, be sure to document those complications. Is there is any secondary compromise such as cardiac or general systems compromise? Be sure to include those findings in your Patient Care Report.
- What did the cardiac monitor tell you about your patient?
- Was there any kind of neurological compromise that is negatively affecting your patient?
- What did you do to counteract the negative secondary symptoms?
The Basics
Naturally, never forget the basics.
Always document…
- Vital signs
- GCS
- Level of Conscious
- Mental Status that varies from the patient’s baseline
- Presence critical labs prior to EMS activation (however, negative values alone, minus signs and symptoms of a serious illness event will not constitute justification for payment)
- Any associated pain (include a pain rating on a 1-10 scale, as you normally would do)
Accuracy and the Truth
Field providers must document with enough detail to be accurate and to be truthful. Thereafter, a good EMS billing office should be able to use documentation that is well-prepared to create a billing claim that adequately represents the medical necessity of the transport.
