EMS Patient Care Report Writing | Documentation 101 | Part 8 – Treatment
Welcome to Part 8 in our continuing blog series “EMS Patient Care Reporting Writing/Documentation 101”.
Part 1: EMS Patient Care Report Writing
Part 2: Field Notes
Part 3: Patient Demographics
Part 4a: Nature of Dispatch – Emergency vs. Non-Emergency
Part 4b: Level of Service
Part 4c: Dispatch – BLS Level of Service & Routine Transports
Part 5: Arrived on Scene and Chief Complaint
Part 6: Signs and Symptoms
Part 7: Mileage and Odometer Readings
Part 8: Treatment
If you’ve been with us from the start you’re actually reading the tenth installment of our blog feature covering effective Patient Care Report writing.
This week, we’ll be covering putting together the part of your Patient Care Report that focuses on the treatments that you provide for your patient.
Hands On
This is the part of your Patient Care Report where you record in words the treatments provided to your patient. This section is really all about recording the skills and use of equipment and supplies in order to address the patient’s overall condition and the reason why the patient activated the EMS system in either an emergency or non-emergency situation.
Be Specific
The secret to documenting treatments is to be specific.
Of course we always want to be very specific about the skills we used to treat the patient and overcome or mitigate the medical scenario we are presented with. This can be the skills and equipment you use to overcome a life and death situation, an explanation of continuing ongoing treatment (such as maintaining treatments the patient presented with as in an inter-facility transport) or it may be skills and equipment used to keep a patient comfortable or properly positioned.
Why Is Transportation by any other Means Contraindicated?
Documenting treatments goes a long way to answering the vital medical necessity question; “Why is transportation by any other means contraindicated for this patient?
If the patient requires EMS treatments, including your skills as a provider, ambulance equipment and supplies in order to maintain life function or at least in order to not exacerbate ongoing conditions, then it is obvious you have answered this question and have established medical necessity from a billing standpoint.
This one section of our discussion solidifies our case for payment from most insurance sources, one way or the other.
Emergency/9-1-1 Documentation
Documenting treatments is often a case of equipment and numbers.
You arrive on scene, assess the patient, obtain his/her chief complaint and a history of present illness/injury and then you put in play the necessary plan of action for addressing your patient’s situation.
Of course here is where you lay out your plan of action and record how you followed that plan. Your local and State treatment protocols were most likely followed as per the scenario and your documentation would detail how you acted within the scope of those protocols to mitigate your patient’s emergency.
Important here is making sure you explain the scenario you were presented with including how the patient presented to you and then how you intervened using your knowledge, skills and the equipment from your ambulance to address the emergency.
Here’s where you explain what “stuff” you used to intervene.
ALS
ALS providers will certainly record medications administered, IV fluid therapy including specifics regarding access device sizes, drip rates, fluid totals, types of fluids, treatment attempts, successes and failures and a host of related items.
Cardiac monitor use must certainly be detailed including rhythm interpretations, notations of abnormalities and heart rates, explanations or arrhythmias then tied to the treatments to attempt to correct that situation.
Critical incidents such as cardiac arrests and/or traumas must be extremely detailed in nature and would include potential explanations of multiple interventions employed during the incident. In these situations you will be getting into documenting things like intubations, for example, such as the types of tubes (ET, Combitube, King LT and corresponding sizes) and the depth of the tube such as recording the numbers in centimeters (as marked on the size of the tube) and noting placement depth (ie. lips, teeth, etc.), for example.
Physician orders and directions are definitely recorded and explained as part of your documentation, including orders for medication administrations and infusions while noting the name of the physician giving the order, as well.
BLS
BLS providers will be noting treatments not unlike ALS providers with the difference simply coming in at the difference between the two scopes of practice.
BLS documentation will include noting treatments such as splinting, bandaging, vital sign recordings, oxygen administration and in some states BLS skill documentation and treatments may also include IV access and fluid initiation.
Pulse oximeter readings can come into play here and skills using supplies such as C-Pap or even, where permitted, may include epi-pen use.
Of course, BLS providers should document any treatments that were provided to assist an ALS provider if such collaboration is part of the scenario.
Outcomes
When explaining treatments the logical progression is to then explain the outcome of that treatment, be it positive or negative.
How did the patient respond to the treatment? Did the patient’s condition improve? Was the patient more comfortable, less comfortable? Is the patient’s condition becoming worse? If so, what treatments were changed? What treatments were added?
This part of your documentation of treatment is vital in that not only are you recording what was done, but it is most important to note the effect your treatment had and its success or failure with a decision to stay the course or move to another action within your scenario.
If you didn’t write it, you didn’t do it!
It’s important to remember that any treatment not recorded in the Patient Care Report was virtually not provided in the final analysis. We all learned in our first EMS classes that famous phrase “If you didn’t write it, you didn’t do it!”
What’s not on the PCR cannot be proven. Remember this Patient Care Report is a legal document. It must be prepared precisely, in detail and be the full written record of your EMS incident without fail. It is the only written record of your EMS incident, be it emergency or non-emergency and it must be detailed.
Another Piece of the Puzzle
There you have it. Another piece to the PCR puzzle has been provided to you. Over the past ten weeks we have been dissecting important elements that must be recorded as part of the PCR you write and turn into the billing office for billing of the claim for payment.
Thanks for following our blog.
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. If you have any questions, be sure to e-mail your contact here.
Let me know what this series is doing to help you become a better Patient Care Report writer. E-mail us with any suggestions you may have for topics we can cover as part of this series.
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