How to Write Good Patient Care Reports (PCRs) – Part 1 of 5

How to Write Good Patient Care Reports (PCRs) – Part 1 of 5

 

Part 1 (of 5): Collecting Patient Information

 

An often underrepresented issue that EMS staff need to work on is writing detailed patient care reports (PCRs) that provide a clear clinical picture of the patient’s needs. While providing the best care for the patient is important, it’s vital that this care be accurately reported.

Why should this be your concern? For many EMS services, the bulk of revenue comes from insurance reimbursements. An incomplete or inaccurate PCR may result in a denial of reimbursement for services from the insurance company or even a demand for a refund after payment has already been made. Continued patient care can also depend on well written PCRs, as receiving facilities may use these as a guide to what treatment patients have already received and for future treatment plans.

This series focuses on 5 criteria EMS staff need to review while writing PCRs. Each month we will focus on one new criterion.

Encourage your staff or colleagues to use these criteria as guidelines to writing complete and accurate PCRs that reduce the chance of insurance denials.

 

Criterion 1: Are you collecting all necessary patient information for your PCRs?

 

While completing each PCR, report all the following information:

 

Detailed dispatch information

This information validates the reason and level of response.

Example: Unit 1 responded to report of chest pain with dizziness.

 

Patient demographic information

Make sure to include the patient’s full name, current address, phone number and date of birth in order to bill the insurance company and receive reimbursement for services.

 

 

Patient insurance information

Collect all insurance information for billing in one go by obtaining copies of insurance cards. Having a scanner on your rig would prove a sound investment to obtaining these copies. Obtain copies of the patient’s insurance card from the receiving facility if you were unable to collect it during transport.

 

Chief complaint

What medical conditions did the patient indicate upon arrival? When did the symptoms start?

Example: 62 y.o. male states onset of chest pain with dizziness approximately 15 minutes before calling 911. Patient states he was mowing the yard when he had the onset of chest pain.

 

Detailed primary and secondary assessment information

What signs and symptoms did the patient communicate during your assessment? What were your clinical findings?

Example: Patient indicates no pain on palpation during examination of sternal and chest areas. Patient states chest pain radiates to right arm and denies difficulty breathing at this time. Patient’s skin is cool, pale, and moist to touch. Pulse is equal on both wrists at 85, and is irregular.

 

Detailed information about medical procedures performed and their outcome.

Example: IV established in left hand with 18 gauge rate TKO. Patient received three aspirin (324 mg) P.O., nitro sublingual. Patient indicates no pain relief after nitro. ECG established shows sinus rhythm as irregular with a rate of 86 and multifocal PVCs.

 

Your impression

Using the information obtained, what do you think is clinically going on with the patient?

Example: chest pain cardiac related, cardiac dysrhythmia, dizziness

 

Link to part 2: How to Write Good Patient Care Reports Part 2 (of 5): Avoiding Vague Terminology in Patient Care Reports

 

Grant Helferich is employed as the EMS Advisor/Client Trainer with Omni EMS Billing in Wichita, Kansas. He is a former member of the KEMSA Board and has also served as the treasurer and president of the KEMSA Administrator’s Society. He was certified as an EMT, EMT-I, M.I.C.T. , and T.O. II. Grant has worked EMS for over 35 years in roles such as an EMT, EMT-I, M.I.C.T., Field Supervisor, Flight Paramedic, Cardiovascular Specialist, Assistant Director, and Director of EMS.

6 Tips to Follow When Documenting Patient Pain

 

We know you take good care of your patients. You know you take good care of your patients. But insurance companies reimbursing your claims don’t know how well you take care of your patients. It’s up to you to tell them.

What’s the best way of doing this? A detailed assessment of the patient AND the patient’s chief complaint during transportation. Part of this process is completely and accurately documenting the patient’s pain.

Following these tips when documenting patient pain does double duty:

  1. it allows the receiving facility to get a complete and accurate picture of the patient’s pain in order to give quality continued care, and

  2. it increases the likelihood of your claims getting paid by insurance companies.

 

Tip 1: Document the SEVERITY level of pain

On a scale of 1-10 (with 10 being the worst), how much pain does the patient report experiencing?

 

Tip 2: Document what causes VARIABILITY of pain

What increases the pain (movement, palpation, bearing weight, etc.) and what reduces the pain (ice, elevation, not moving the affected area, etc.)?

 

Tip 3: Document the MOVEMENTS of the patient at pain onset 

What was the patient doing at the onset of pain (e.g. mowing lawn before onset, climbing a ladder and fell down, sleeping and was awakened by pain, etc.)?

 

Tip 4: Document the LOCATION of pain 

What is the specific location of the pain? Be as specific as possible and include the laterality of the pain (which side of the body, and which specific body part is experiencing pain: e.g. pain is in the lower right arm, instead of just saying “arm pain”). Medicare and several other insurances require laterality when coding for insurance claims. If patient is experiencing abdomen pain symptoms, document which quadrant of the stomach is the pain is located in (e.g. patient is experiencing pain in the lower left quadrant of the stomach).

 

Tip 5: Document the TIME of pain onset

What time or how long ago did the patient report the pain starting? Remember to be specific!

 

Tip 6: Document your EVALUATION of the pain site

What did you find at the pain site? Was there swelling, deformity, bruising, tenderness, etc.? Was the patient guarding the area of pain?

 

Grant Helferich is employed as the EMS Advisor/Client Trainer with Omni EMS Billing in Wichita, Kansas. He is a former member of the KEMSA Board and has also served as the treasurer and president of the KEMSA Administrator’s Society. He was certified as an EMT, EMT-I, M.I.C.T. , and T.O. II. Grant has worked EMS for over 35 years in roles such as an EMT, EMT-I, M.I.C.T., Field Supervisor, Flight Paramedic, Cardiovascular Specialist, Assistant Director, and Director of EMS.