Part 3 (of 5): Justifying Medical Interventions
Last month, we shared the second part of a 5-part series on writing good patient care reports (PCRs) that focused on avoiding vague terminology (See Full Article: How to Write Good Patient Care Reports (PCRs) Part 2 of 5: Avoiding Vague Terminology in Patient Care Reports).
This month we will be focusing on justifying medical interventions documented in your PCRs.
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 3: Are you justifying the medical interventions reported in your PCRs?
It’s important to fully explain the reasons why you provided the medical interventions documented in your PCR. Don’t think of it as just providing detailed information to insurance companies to reduce denials of claims. You are also providing continued care for the patient, as the receiving facility gets a complete picture on what care was provided to the patient and the outcomes of that care.
☑ Provide a clinical reason for performing a medical procedure.
Always explain in clinical terms why you used a particular medical intervention during a transport. For example, stating that you applied an ECG monitor due to medical protocol is not a clinical reason for using the ECG monitor. Explain the clinical reasons or why the patient would benefit from each medical intervention.
Example: ECG monitor was applied to patient to rule out any cardiac conditions associated with the patient’s onset of weakness.
☑ Include information about the outcome of the medical intervention.
If there was a change in the patient’s condition, document the change and how you assessed it.
Example: ECG impression using a 4 lead is RSR without ectopics. Heart rate is 80.