On Drop Downs and Written Narratives- Connecting the Data in our PCRs
“Paint a Picture”
We read a lot of communication that point to expectations. The Centers for Medicare and Medicaid Services (CMS), State agencies and even Commercial Insurance payers bombard our billing office with all kind of communication about what they expect to be the supporting documentation relative to your EMS incident.
One common phrase pops up time after time… “Paint a Picture” in words about the medical necessity and reasonableness of each transport.
But, what about the Drop Downs?
Given our very tech-driven world today, it does not surprise us at all why we continually field questions from client provider staff when we conduct documentation training sessions about the need to include a written narrative in the PCR.
Our answer is and has always been…there has never been a data-driven, drop-down menu generated documentation piece yet that “Paints a Picture” about your EMS scenario. Data is important but the explanation part that ties it all together must include words.
Enlighten Yourself with PCR Review Initiatives
Every EMS provider must think about whom it is that’s going to read and review the Patient Care Report after the EMS incident has been completed.
A great exercise to become involved with at some point in your EMS career is a documentation peer review exercise. Peer review and QA/QI exercises are very enlightening and help to make all of us better at what we do.
It’s always clear when reviewing PCR’s that the most compelling cases in support of medical necessity and reasonableness of the patient in any EMS incident are made when the chart contains a well-written narrative piece.
It’s never difficult to separate the “hit-the-generate-button” charts from the manually-written ones. In all cases, it is the opinion of our staff that the PCR’s that contain a written narrative generated from brain to keyboard are far more compelling and complete versus those incidences when the overall presentation of the chart is derived from a conglomerate of the compilation of the pull-down menus.
Efficiency aside, when pressed to support the billing or legal aspects such as in an audit or post-care reviews, there is no doubt in our minds that the PCR’s with the nicely prepared and explicit sentence/paragraph structure present a clearer picture in words of the EMS incidents they represent.Those well-written charts not only tied everything together nicely but left little doubt about the patient’s need or lack thereof depending on the scenario) for ambulance treatment and transport . Plus those nicely balanced charts back-up the use of certain intervention skill sets and prove that those skills addressed the patient’s need for EMS.
The Anatomy of a PCR- Ligaments and Tendons…
At no time should EMS documentation be ambiguous. Yet, fractured data elements naturally become ambiguous unless there is a written tie.
Think of your written narrative as being the ligaments and tendons of your PCR. Here we draw an anatomical analogy to help make our point.
So, the bones and muscles are all those drop down menus detailing the facts about your EMS treatment and transport scenario. But we all know that without ligament and tendons, all those bones and muscles in our body would not function because there would be nothing to hold them together.
Your words hold it all together.
Put another way, think about the last item you purchased that had to be assembled. We’re sure there were pictures and diagrams to help you along in the assembly process; but wasn’t it the words beneath or in between all the pictorial guidance that helped you understand exactly what to do with all of those parts?
So think of your PCR in the same manner. Someone after you will need to put all the pieces of your incident together. Supervisors, billers, reviewers, medical directors…you name it. All need a surefire way to monitor your EMS incident that is going to drill into the very core reason of the patient’s need for EMS.
A Conscious Effort…
From here on, we encourage you to make a conscious effort to think through how the next PCR you prepare can be more descriptive as you expertly fill in the blanks between the data with your memory of the incident translated into words.
This step will empower you to become a better documenter and your PCR’s will stand out from amongst your peers. Master the art of balancing the drop downs and use words to help it all make sense!
