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Documentation Guidelines for BCEMS

Documentation is one of the most important tasks that we perform as pre-hospital providers, but also one of the most dreaded. While there are many reasons to document, the main purpose of documentation is to provide an accurate, comprehensive, permanent record of each patient’s condition and the treatment rendered, as well as a data collection tool. This course will discuss the reasons we document, what needs to be included in all patient care reports (PCR’s), and special situations such as refusals and medical necessity forms.

WHY DOCUMENT? [top]

There are 5 main reasons to document EMS calls: Clinical, Legal, Operational, Financial, and Compliance.

Clinical: As pre-hospitals providers our first and most important job is to provide patient care. It is essential that all patient care and assessments be accurately recorded. This includes the patient’s primary complaint; the patient’s presenting signs and symptoms (assessment), and all treatments and interventions, both attempted and successful. Because the patient care report is first and foremost a clinical document, it provides a clinical picture for subsequent care providers such as ER doctors, trauma or cardiac services, and admitting physicians. In order for this information to be of value to the receiving facility it is important that a copy of the PCR be given to the receiving facility. NCOEMS and local medical control have both made a requirement that a copy of the patient care report be left with the receiving facility.

ScaleLegal: As well as being a clinical document, the patient care report is also an important legal document. In the case of a malpractice suit, the PCR will be one of the primary items reviewed to determine if the standard of care was met. Because the patient care report is a record of the patient’s condition and all treatment, it will be closely examined when legal issues in patient care are raised. In addition to malpractice the PCR can be used in criminal and other civil cases, such as injury liability. These cases do not occur at the time of the incident, but often months, even years later.  A well written patient care report serves as a substitute memory for the EMS provider after the patient was transported. It is important that the patient care report be completed as close to the time of the call as possible. When a call report is completed hours or days after a patient encounter details are forgotten and important information can be left out. It is these details that can make a difference when legal questions are raised down the road. If information about care and treatment of a patient is not documented, it is considered that it did not happen.

Floppy DiskOperational: One of the least thought about reasons for documentation is that of operational issues and data collection. EMS operations are driven by data; response times, call-to-intervention times, interventions performed, or success rates to name just a few. NCOEMS requires that all providers attempt to collect over 200 data points on every patient encounter.  The local Peer Review Committee uses this data to evaluate system performance each month. The evaluation of key data points ensures that performance of high risk procedures are successful on a consistent basis, and can help identify issues with patient care before adverse events happen. Additionally the collection of patient care data can help measure if care being rendered is having a positive effect on patient outcome. This helps drive future patient care, insuring that interventions that actually work are being done. But, in order for this data to be of any value it is important that the data be entered in the first place. This means that pertinent data fields should be entered as completely as possible on every call.

Dollar SignFinancial: Financial reasons are probably the most reinforced reason for documentation. Proper documentation is directly related to reimbursement from Medicare/Medicaid and insurance. Reimbursement rates are based on the level of care provided; an ALS transport will receive a higher reimbursement rate than a BLS transport. This means that every aspect of patient care must be accurately and completely documented, this includes assessments and all interventions.  Medicare allows an ALS rate even if no ALS procedures are performed. In order for Medicare to pay the higher rate, an ALS assessment by a paramedic must be documented and noted that no ALS interventions are needed. Also needed for financial documentation is the patient’s signature, or an authorized signer on the patient’s behalf, to assign the patient’s benefits to the provider of healthcare services. This gives healthcare provider, or its representative, the ability to bill directly to the patient’s insurance provider. If the patient’s signature is not obtained at the time of transport, the billing company must track down the patient in order to get permission to obtain needed information. By having the patient sign at the time of transport is not only more convenient, it also saves time and decreases the time it takes to receive reimbursement.

Compliance: The final reason for proper documentation is that of compliance. EMS is regulated by federal, state, and local rules. Compliance is verified thru documentation. Things such as HIPAA notices and medical necessities must be properly documented to meet federal requirements. Also, if the EMS system is receiving grant related funds, it often is tied to performance improvement. Compliance with the terms of the grant and showing improvement is tracked thru proper documentation.

WHAT HAS TO BE DOCUMENTED [top]

Now that we know why we need to provide good documentation, what needs to be documented? Good documentation tells a story of why EMS was requested and what EMS did for the patient. There are several ways to tell this story; SOAP, CHART, or a chronological listing to name a few. No matter the way the story is told there are key components that must be documented.

  1. Times and Dates. Make sure that all times and dates are recorded and correct. The use of CAD data makes this easy, but computers are only as reliable as the people using them. Times do not always get entered in to CAD. Any missing times must be entered.
  2. Addresses of scene and destination. Addresses should included city and county.
  3. Reason for dispatch and mode of response. What was the dispatch complaint and how where you dispatched?  “Responded emergency reference chest pain”.
  4. The patient’s complaint on arrival. What was the patient’s primary complaint? Use the patient’s own words to describe the complaint when possible. “Patient describes pain as “crushing sensation in center of chest””.
  5. Patient assessment. A primary assessment, including vital signs, must be completed on every patient contact. This includes transports and refusals.
  6. Patient demographics. Accurately record the patient’s name, mailing address, DOB, SSN, and telephone number as completely as possible. Verify that all information is correct and spelled correctly, especially the patient’s name (Green vs. Greene, or Cathy vs. Kathy). Do not rely on hospital information as your sole source of information, ASK THE PATIENT!
  7. Patient history, medications, and allergies. Obtain a list of the patient’s past medical history, all medications taken by the patient, include non-prescription medications if possible; and a list of any allergies the patient may have.
  8. Treatments. A complete listing of all interventions and medications must be entered. It is important that the time of all treatments be entered, as well as dosages and routes for medications.  The patient’s response and any complications should also be recorded. Be sure to include both successful and unsuccessful attempts.
  9. Billing information. Every attempt should be made to obtain the patient’s insurance information. This includes the insurance company name and policy number. Copies of the cards can be scanned attached to the patient care report. If the patient is covered by another person’s insurance (such as a child), the name and demographic information of the responsible party should be obtained.  If the incident involves a work related illness or injury, this should be noted also.
  10. Mileage. The total loaded transport mileage must be documented on every transport. This mileage should be to the nearest tenth of a mile.
  11. Signatures. There are several signatures that should be included on the call report: the signature of the person completing the report, the receiving facility signature, and the patient’s authorization signature. Whenever care is transferred, the receiving provider should sign confirming that they have received report and are taking responsibility for patient care. The name of the person should also be recorded in the patient care report. The patient should sign the authorization statement on every billable call, this includes transports and treat/no transports. This statement authorizes EMS to bill directly to the patient’s insurance and to release information about the patient in order to collect. If the patient is unable to sign, the patient’s authorized representative should sign in his/her place. If there is not an authorized representative for the patient, then the transporting crew should document why the patient was unable to sign and have that witnessed by the receiving facility staff.

An electronic patient care report must be completed on every dispatched call. This includes cancelled calls, not needed, blood draws and move ups. If you are dispatched on a call, you must complete an ePCR. By doing this, we will be able to better track all calls, not just the ones that we check on scene for.

All electronic patient care reports must be completed at that time of transport and a copy of the report left at or sent to the receiving facility. This includes rhythm strips and 12 lead ECGs. This should be done for every patient transported. If you are called out of the hospital before completing a call report, it must be completed as soon as possible. All call reports are to be completed by the end of the shift; this includes refusals and cancelled calls, DO NOT PUT IT OFF!!

SPECIAL SITUATIONS [top]

REFUSALS: Whenever a patient refuses to be transported, this opens the providers and their agency up to increased risk. Documentation provides a level of protection if a complaint is made or an adverse outcome happens after a refusal. It should first be noted that as prehospital providers we should never provide a diagnosis to the patient and we should never give advice which would encourage a patient to refuse treatment or transport. In those cases where the patient refuses treatment or transport there is important information that should be documented. A complete assessment should be documented on every refusal. This includes the patient’s chief complaint, vital signs, and a complaint specific physical assessment. You should also consider obtaining an ECG/12 lead if applicable. These assessments could be a key piece of information for the patient to help persuade them to agree to be treated and/or transported. By documenting that this information was obtained, it shows an effort of EMS’s part to give the patient this information. The EMS provider should also document any additional efforts performed to inform the patient, such as talking with family members, the patient’s personal doctor, or online medical control. Another key piece of documentation is the patient’s signature on a refusal form. The patient must understand the refusal form prior to signing. Reading the 4 key points of the refusal to the patient is the easiest way to make sure that the patient understands the refusal form. It should be documented in the narrative that the refusal was read to the patient. The patient must be alert and oriented, and not under the influence of drugs or ETOH in order to be able to refuse care. After the patient signs the refusal it is important that the signature is witnessed by a third party. Ideally this signature will be a family member of the patient, or a bystander. Fire department personnel and law enforcement can also serve as a witness. As a last resort, the second EMS crew member can serve as a witness to the refusal. If the patient is a minor, the patient’s parent or legal guardian must sign the refusal. If the patient’s parent is not on scene, they may consent to a refusal over the phone. If a phone refusal is given, it must be verified by both crew members, make sure to document everything that was said in the narrative. If no contact with a parent or guardian can be made, consult with law enforcement and/or medical control. If in doubt, transport the patient to the hospital and let the ER try and contact parents.

MEDICAL NECESSITY: One of the most confusing things pre-hospital providers must deal with is when must a medical necessity form be completed. The Centers for Medicare & Medicaid Services (CMS) sets the standards for when ambulance transportation is covered. CMS requires a certificate of medical necessity for non-emergent transports from skilled nursing facilities, facilities that have full time nursing care. So, the big question is what is a non-emergent transport? First let’s look at what an emergency transport is. CMS defines an emergency transport as responding immediately to a 911 call; this means that EMS resources are dispatched as quickly as possible to respond to the call, not necessarily that lights and sirens where used. Routine responses may not require a medical necessity form.  The patient’s chief complaint is considered when determining the need for medical necessity. Conditions such as abdominal pain, choking, altered LOC, psychiatric/behavioral problems, or suspected fracture may meet CMS requirements, a list of common conditions can be found on CMS’s website, www.cms.hhs.gov/manuals. Documenting the response mode, the patient’s chief complaint and your assessment are critical for meeting CMS standards. CMS defines a non-emergent transport as transports from skilled facilities for non-life threatening conditions when transportation by other means may result in injury or would otherwise endanger the patient’s health. CMS requires that the patient be bed-confined. To meet the requirements to be considered bed confined, the patient must meet ALL 3 of the following requirements:

  1. Be unable to get up from bed without assistance, and
  2. Be unable to ambulate, and
  3. Be unable to sit in a chair or wheelchair.

AmbulanceThis should not be confused with non-ambulatory. Non-ambulatory means that the patient is not able to ambulate without assistance.  It is important to document the patient’s condition, including past medical history, in order to support if the patient is bed-confined or non-ambulatory. A medical necessity form is required for all non-emergent transports from skilled facilities. Transports for routine labs or for scheduled out-patient procedures or surgery will require the completion of the medical necessity form. Anytime that the responding crew feels the transport may need a medical necessity form, the crew should obtain the medical necessity form prior to transporting the patient. If it is not possible to obtain the form prior to transporting, a medical necessity form may be left with the sending facility with instructions to fax to the number listed at the top of the form. Be sure to document that the form was left with the facility; also the run number should be filled in before giving the form to the sending facility. Medical necessity forms must be scanned and attached to all electronic patient care reports. If a medical necessity form is not obtained for a non-emergent transport, the transporting crew will be required to return to the sending facility to obtain the form. It is the transporting crew responsibility to have the form completed if it is thought to be needed. If you are in doubt if the form is required, have it filled out. This will save time in the long run.

LAW ENFORCEMENT BLOOD DRAWS: The recent requirement that EMS provide blood draw services to law enforcement has created issues for EMS. In the past we have not required a patient care report whenever we drew blood for local law enforcement. Recently EMS crews have been called into court to testify regarding the blood draw. In order to better protect personnel, it will now be required to complete an ePCR anytime that blood is drawn for law enforcement. It will not be required to complete a full report, only document needed information. Blood draws will be documented as “No Patient Found” for the disposition. In the narrative, document the subject’s name, the name and agency of the requesting officer, and information about the blood draw (where blood was drawn from, number of tries, and any issues). We will continue to enter the same CAD information into the MCT as we have done in the past. By documenting these blood draw requests using the ePCR system, we have a way to record additional information about the encounter if questions are raised down the road.

CONCLUSION [top]

Granted completing call reports is not the glamorous part of being a prehospital provider. Proper documentation is just as important as the procedures done. If you cannot tell someone what you did, it is as if it never happened. We have seen that there are many reasons to provide documentation, what has to be entered in order to properly document each patient contact and cover several special situations. As the care provider it is ultimately your responsibility to provide proper documentation. This article has covered the required elements for documentation. Remember: IF IT IS NOT DOCUMENTED, IT DID NOT HAPPEN.

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