Top 10 PCR Mistakes and How EMS Can Avoid Them

On an especially busy shift or during long hours, it may be tempting to rush through the electronic patient care record (ePCR), or feel compelled to move on quickly to the next call. However, ensuring that your PCRs are accurate, detailed, and complete is a key component of not only allowing your team’s performance to be reviewed and improved, but ensuring that you are consistently, fully reimbursed by insurance companies and payers, and that lawsuits are avoided.

Today, many top electronic health record software tools make documentation quicker and more accurate, with progressive fields and consistent vocabulary that help ensure records are delivered complete and easy-to-read at the ED. However, it is still vital that teams and supervisors fully understand their role in creating accurate documentation, and how it may later impact business operations for their agency.

At the recent American Ambulance Association (AAA) conference in Las Vegas, EMS attorney Steve Wirth of Page, Wolfberg & Wirth, presented a presentation on the “Top 10 Documentation Mistakes Ambulance Providers Make – and Supervisors Overlook.” Wirth explained that each of these mistakes can affect the clinical, operational, and reimbursement aspects of an ambulance operation.

1. Poor Spelling, Bad Grammar, and Use of Improper Acronyms and Abbreviation
When an ePCR is being carefully scrutinized by a lawyer or reimbursement officer during a contested claim, even the smallest mistakes can be used against an agency. It’s important that the entire team understand the importance of taking the time and effort to enter accurate, clean info and double-check for typos and errors. Some of today’s top ePCR software helps address this issue by offering a “progressive functionality” in forms, identifying mistakes as the provider enters data, and not allowing him or her to move to the next field until the error is corrected. Additionally, drop-down menus and access to online databases and industry codes can help ensure consistent terminology is used.

2. Not ‘Painting a Picture’ of the Patient’s True Condition
A best practice in ensuring the narrative of your ePCR can “pass the visualization test,” meaning that anyone reading the document should be able to clearly visualize the scene. The ePCR serves as your “substituted memory,” and when questions arise, it’s much more effective to rely on a complete ePCR for even the smallest details rather than try to recall them by memory only. Similarly, it’s imperative to create your detailed PCR at the time of transit to ensure accuracy.

Additionally, a more complete ePCR assists with hand-off at the ED, potentially reducing the time it takes for doctors to gather a full understanding of the patient’s condition and prescribe appropriate treatment. Small details might change a treatment plan, so the more complete a report, the better. Digital reports allo for a smooth transition and improve chances for a positive outcome.

3. Making Subjective Conclusions or Stating Opinions
It’s important that you document the call in an objective – not subjective – manner. Again, remember that someone may very well be combing over every detail of your report in the future. Use your ePCR to observe and record factual details that show the reasoning for decisions made by the team, including statements from the patient, information from the surroundings, and medical observations.

4. Internal Inconsistencies
Remember that someone may one day be examining every detail of your ePCR, including how you recorded the patient’s condition is different fields. Inconsistencies or conflicting notation can be used against you, so taking the time to ensure you are consistently recording the condition is key. For example, when documenting a patient’s anatomical view, make sure the symptoms on the front and back views align. If you mark “amputation” on the front view of the right knee, but mark “normal” on the back view, you may raise red flags on the overall accuracy of your report.

5. Improper Addendums or Corrections
It is a provider’s duty to ensure narratives are accurate and honest to the best of his or her ability. Documentation mistakes are going to happen, and you may remember something later that you should have included. It’s important to ensure your ePCR is accurate and honest, so adding an addendum sheet to your report is an appropriate way to correct or update your report. However, you should never change documentation to get a claim paid.

6. Failure to Adequately Address ‘Medical Necessity’ and ‘Levels of Necessity’
Insurance companies and Medicare contractors use ePCRs to ensure that ambulance service for each claim are “justified,” so it’s important that your ePCR adequately details on-scene information, the patient’s condition, and other information that supports the decision to transport. Documenting with as much detail as possible leaves little room for doubts. Some ePCR software offers functionality that includes customized fields and forms, an option for ensuring that your entire team is completing all documentation you feel is important for your agency on each and every call.

7. Failure to Document the Reason for the Transport and Interventions
Again, it’s important to document details that show how transport was necessary and reasonable, to ensure payment by Medicare and other payers. For example, a narrative such as, “On arrival, we found the patient in a hospital bed in the living room,” proves that the patient was bed-confined. It’s helpful for crews to be aware that not every transport will get billed to Medicare; in some cases, another payer will be responsible. The more complete your report, the fewer questions later, and the better the chances that your agency will spend less time on contested claims.

8. Failure to Obtain Necessary Signatures
On-site signatures verify that ambulance services were actually provided. You should always obtain signatures from the patient or a representative, as well as those who order patient services or those who perform health services (it’s recommended that both crew members sign). If you encounter a Patient Unable to Sign (P.U.T.S.) or Representative is Unavailable or Unwilling To Sign (R.U.T.S.), you’ll need a statement documented from the crew verifying this with explanation, as well as the signature of a receiving facility representative. Again, a customized field can be included in your ePCRs so that it cannot be marked complete without one of these options included.

9. Failure to Record Patient-Loaded Miles
Remember that Medicare and many other payers will only pay patient-loaded miles to the closest appropriate facility. Ensure that you are recording odometer readings – down to the tenths – from the point of pickup to the patient destination. A GPS device is a good supplemental tool for this as well.

10. Second Guessing and Making Improper Assumptions
It’s natural for your observation skills and job history to form your opinion of what is going on; in fact, it can help you ascertain the situation and make proper first steps. However, when it comes to documentation, you need to be able to support with facts your reasons for your course of action.

For example, avoid stating general comments like, “Patient was drunk.” Instead, include details that paint the scene, like “Patient is sitting at bar, with head resting on his forearms asleep with an alcoholic beverage still in his hand. He has a noticeable odor of alcohol on his breath. When he awoke, his speech was very slow and slurred and he told us he had 6 whiskeys in the last 2 hours. Family member states he was drinking all day.” Similarly, refrain from adding side comments or unprofessional remarks that may color your report, like “Patient definitely did not need transport. This was a waste of my time.”

All of these mistakes can be greatly reduced by taking advantage of ePCR software functionality and ensuring your entire team is trained and aware of your agency’s expectations. Some officers choose to survey a certain number of random ePCRs each shift, incentivizing people to always complete their reports in case theirs are selected. And by utilizing the customization features in today’s top ePCR software, you can make it easier and faster than ever for team members to be able to complete their records in a timely manner without negative impacts to their workload.

Take a tour of ESO’s ePCR software tool, Electronic Health Record.

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