How to Write a PCR Narrative That Saves You Time and Money
Completing patient care reports (PCRs) during your shift can seem like a tedious task, but it is essential to the operations of an EMS agency. A thorough and accurate PCR not only helps ensure a patient will receive the most appropriate care, but also offers insight into quality of care provided. Having access to quality data enables your agency to continuously improve processes and procedures. These data also help optimize billing and reimbursement, a key factor in keeping your agency running.
Today, many EMS agencies use an electronic patient care report (ePCR) system to help their teams document more efficiently. The digital nature of ePCRs makes patient records easier to store, sort, and securely share. However, the quality of the information that comes from an ePCR is only as good as the quality of information that is entered. The narrative section of the ePCR is especially important in providing a full account of calls.
Spending a few additional minutes to ensure your ePCR narrative is complete and accurate could potentially save your agency time and money down the line, whether by ensuring full reimbursement from payors, avoiding a lawsuit, addressing contested claims of medical necessity, or answering care questions. A good ePCR helps protect both your patients and your crew.
How to Write an Effective ePCR Narrative
Following a few best practices can help you create more complete documentation in your ePCR narratives and help you avoid having to go back in fill in missing details or redo your work. Creating thorough documentation while the details are fresh in your mind can save you valuable hours later and ensure the record is as accurate and as complete as possible.
1. Be concise but detailed.
Be descriptive in explaining exactly what happened and include the decision-making process that led to the action. What is your general impression? Describe what you see when you arrived on the scene. What is the patient doing? What position is the patient in? Use quotations when appropriate. Put the reader of your report in your scene. Including the “why” behind a decision can help answer questions that may come up down the line or help support medical necessity.
While it is not the sole purpose of the narrative to justify medical necessity, it is intended to be an accurate, factual assessment that a billing professional can evaluate against their individual organization’s medical necessity criteria. The more details you include in your decision-making process, the easier this becomes.
2. Present the facts in clear, objective language.
Include information like statements from the patient, a description of the surroundings, and medical observations. Make sure the narrative is structured in a logical order and include treatment and transport decisions. Using an established method of documentation like CHART or SOAPwill help ensure that your narratives are structured consistently and include important details. Other important details to include are SAMPLE (Signs and Symptoms, Allergies, Medications, Past medical history, Last oral intake, and Events leading up to present injury) and OPQRST (Onset, Provocation, Quality of the pain, Region and Radiation, Severity, and Timeline).
3. Eliminate incorrect grammar and other avoidable mistakes.
A spelling error or incorrect acronym could potentially change the meaning of the narrative or lead to unnecessary confusion. Always proofread your narrative, or even ask a teammate to review the narrative for you. Some of today’s top ePCR software helps address potential errors by offering “progressive functionality” in forms, identifying mistakes as the provider enters data and preventing moving on to the next field until the error is corrected.
Of course, it’s important to always keep your narrative professional and free from any extraneous comments that could be construed in a negative light. Refrain from any jokes or off-color comments; this form may be pulled one day in a legal situation and everything you include could one day been seen by another audience.
4. Be consistent and thorough.
Make sure all relevant information is included in the narrative in a manner that is consistent with your agency’s standards. Always include details like reason for transport, interventions, and number of patient-loaded miles. Consult with your medical director to set best practices for documentation terminology (terms like “field diagnosis,” “impression,” “differential,” and “medical decision making”) for your ePCRs. Software that includes drop-down menus, access to online databases, and industry codes can also help ensure consistent terminology is used in reporting.
Always obtain the necessary signatures verifying that ambulance services were provided. Some ePCR software offers functionality that includes configurable fields and forms that help your team complete the specific documentation that is most important to your agency. These fields make it easier to pull metrics when working on QI/QA projects, reporting to agencies or organizations, or telling your agency’s story.
Time Invested Now Pays Off Later
Taking the time to develop narratives that are thorough, accurate, and complete ensures that you are providing the best patient care possible while contributing to keeping your agency running smoothly. As the saying goes, “An ounce of prevention is worth a pound of cure,” and it’s true when it comes to how you spend your time immediately following a call.
A complete ePCR can save you hours of headache trying to remember missing details, justifying your team’s actions, or tracking down missing data points from other sources. It can also help take your team performance – and, ultimately, the care you provide to your community – to a higher level.
Explore how your ePCR software can help you document patient information more efficiently and ensure that your team is trained and aware of your agency’s expectations. Take a tour of ESO’s ePCR software tool, ESO EHR, to see how it can help your agency more efficiently develop stronger clinical documentation.