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 patient care record (PCR), 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 tools make documentation quicker and more accurate, with step-by-step 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 talk on the “Top 10 Documentation Mistakes EMS Providers Make – and Supervisors Ignore.” Wirth – who was one of central Pennsylvania’s first paramedics and served 40+ years in public safety – now works with his firm to educate and serve the unique needs of the first response community in categories like compliance, transactional law, revenue cycle management, and human resources.
During his presentation, he offered real-world examples of good and lacking PCR documentation, illustrating how EMS agencies can improve the likelihood of quick and full payments, while also avoiding costly litigation. The most common PCR mistakes include:
- Poor Spelling, Bad Grammar, and use of Improper Acronyms and Abbreviation
When a PCR 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.
- Not ‘Painting a Picture’ Patient’s True Condition
A best practice in ensuring the narrative of your PCR can “pass the visualization test,” meaning that anyone reading the document should be able to clearly visualize the scene. The PCR serves as your “substituted memory,” and when questions arise, it’s much more effective to rely on a complete PCR 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.
- 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 PCR to observe and record factual detail that show the reasoning for decisions made by the team, including statements from the patient, information from the surroundings, and medical observations.
- Internal Inconsistencies
Remember that lawyers, payers, or reviewers may one day be carefully examining every detail of your PCR, down to 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 accuracy of your report.
- Improper Addendums or Corrections
It is a provider’s duty to ensure narratives are accurate and honest to the best of their ability. Documentation mistakes are going to happen, however, and you may remember something later that you should have included. It’s important to ensure your PCR is accurate and honest, so adding an addendum sheet to your report is a good way to correct or update your report. Never change documentation to get a claim paid, however.
- Failure to Adequately Address ‘Medical Necessity’ and ‘Levels of Necessity’
Insurance companies and Medicare contractors use PCRs to ensure that ambulance service for each claim was justified, so it’s important that your PCR 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.
- Failure to Document the Reason for the Transport and Interventions
Again, it’s helpful 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 good for crews to be aware that not every transport will get billed to Medicare; in some cases, another payer will be responsible.
- Failure to Obtain Necessary Signatures
On-site signatures verify that ambulance services were actually provided. Many electronic PCRs include a field for this, or you can find a sample ambulance signature form on Wirth’s website. You should obtain signatures from the patient or a representative, as well as those who order patient services (can be PCS for non-emergency transports), as well as those who perform health services (it’s recommended that both crew members sign). If you encounter P.U.T.S (Patient Unable to Sign) and R.U.T.S. (Representative is Unavailable or Unwilling To Sign), you’ll need a statement documented from the crew verifying P.U.T.S./R.U.T.S. (and why), as well as the signature of a receiving facility representative.
- 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.
- 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, “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 that may color your report, like “Patient definitely did not need transport. This was a waste of my time.”
Finally, an important additional element that Wirth strongly recommends is a post-call wrap-up with the crew, which he describes as a “Plus-Delta” debriefing. This meeting should be quick, informal, and non-threatening, and use a simple two-column chart to list what worked well (the “Plus” column) and what would you change (the “Delta” column). This also allows you the chance to recall anything not included in the PCR and make an addendum at that time.
By investing a few extra moments of effort at the time of transport and immediately afterwards can save you hours of headaches in the future, not to mention costly lawsuits or a lack of reimbursement. Additionally, accurate PCRs can help teams improve their patient care and efficiencies, making their jobs more effective and productive. Avoiding these top mistakes can help EMS agencies realize immediate improvement in their records and processes.