By Matthew Konya We can all agree that completing a patient care report (PCR) may not be the highlight of your shift. But it is one of the most important skills you will use during your shift. Of course, patient care is the No. 1 priority of an EMS professional, and it is important to remember that completing a timely, accurate and complete PCR is actually a part of the patient care we provide . A complete and accurate PCR is essential for obtaining proper reimbursement for our ambulance service, and helps pay the bills, keeps the lights on and the wheels turning. The following five easy tips can help you write a better PCR:
One of the biggest pitfalls of PCR completion is not being specific enough. A main function of the PCR is to gather the information your service needs to bill for the call. For this to happen, the PCR needs to be detailed enough to allow the billing staff to properly code and bill for the call. Ambulance services, including the treatments and interventions provided to the patient – need to be medically necessary to be reimbursed by Medicare and other payers – and that is determined primarily by reviewing the PCR. A primary way to determine if medical necessity requirements are met is with documentation that specifically states why you took the actions you did on a call. For example, simply documenting “per protocol” as the reason why an IV was started or the patient was placed on a cardiac monitor is not enough. Only documenting “per protocol” does not give enough information to establish medical necessity. Did you start the IV because the patient was dehydrated, or because the patient needed D50? Was the cardiac monitor applied because the patient complained of chest pain, or was it applied because the patient had an irregular pulse? Questions like these are not answered by simply documenting “per protocol.”
When completing a PCR instead of documenting, “per protocol,” explain why you took the actions you did; for example: “18 gauge IV established in right AC due to patient being in SVT and need for intravenous administration of adenosine.” This specifically explains why an IV was established on the patient and states facts that can be used to show medical necessity for the call.
The same can be said for non-emergency transports between two hospitals. Simply documenting that the patient was transported for a “higher level of care” is not good enough. It is essential to document the specific procedure or care that the patient requires at the receiving hospital that is not available at the sending hospital.
PCRs should go beyond merely stating that a patient was picked up at a certain location, transported to another location and that the transport was “uneventful.” The PCR should tell a story; the reader should be able to imagine themselves on the scene of the call. Your PCR should never leave the reader asking questions, such as why an ambulance was called, what the initial patient’s condition was upon arrival or how the patient was moved from the position they were found in to your stretcher and ultimately to the ambulance. To paint a picture of the call, your PCR should be written accurately, objectively, clearly and it must completely document all relevant events of the call.
EMS professionals have long been promised a PCR that basically writes itself. Electronic PCR software is a great tool and can improve the efficiency of PCR completion. However, simply clicking a box or making a selection from a drop-down menu cannot be a substitute for your words in the form of a clear, concise, accurate and descriptive clinical narrative.
An EMS provider can select “yes” to the checkbox that the patient experienced chest pain, however that is not enough information. How did the pain feel to the patient, did the pain radiate to any other part of the body, did anything make the pain better or worse? This is just one example of questions that can only be answered by the provider putting pen to paper, or finger to keyboard in creating a clinical narrative. It is the narrative portion of the PCR that not only supplements, but explains the data points created with the checkboxes and drop-down menus you use.
Most states, and many EMS agencies themselves, often have time limits within which the PCR must be completed after the call ended – 24, 48 or 72 hours are common time limits. While it is always important to comply with time limits, there are benefits to getting your PCR completed as soon as possible – preferably right after the call is completed and before your shift ends.
In a perfect world, every PCR would be completed before the next call, however we all know that is usually not the case. There are days when it is impossible to get time to eat, let alone complete a PCR.
Writing the PCR as soon as the call is over helps because the call is still fresh in your mind. This will help you to better describe the scene and the condition the patient was in during your call. Plus, the farther we get away from the call, the more likely we are to forget important details of the call or get them mixed up with other subsequent calls.
Writing the PCR as soon as possible after the call will help make sure it is as accurate as possible. If it is not possible to write the PCR as soon as the call is over, simply taking some notes on the call, and then using those notes later when completing the PCR can ensure accuracy.
The easiest way to improve your PCR is to proofread before submitting it. We understand the dilemma, after writing the sixth PCR for the day, and having 10 minutes left in the shift, the last thing anyone wants to do is sit there and reread what they have just written. But that is exactly what needs to be done.
Poor grammar and spelling is the easiest way to have your abilities called into question by outside observers (e.g., other healthcare providers and jurors evaluating your care in a court case). Most people who read your PCRs will have never met you. They have no objective way to judge your professionalism and patient care abilities, except through the PCR you complete.
Taking as little as five minutes to proofread your PCR can make a big difference in catching errors and improving accuracy. Having your EMS partner also review your PCR is a great check and balance to further ensure accuracy. Going back to the basics taught in primary school can have a major impact on the quality of your PCR writing.
Just as we train to improve our patient care skills, we should also constantly train to improve our documentation skills. Every professional EMS practitioner needs to work at continually improving PCR completion as a core skill which is an essential aspect of patient care.
This article was originally posted in December 2017. It has been updated.
For over 20 years, PWW has been the nation’s leading EMS industry law firm. PWW attorneys and consultants have decades of hands-on experience providing EMS, managing ambulance services and advising public, private and non-profit clients across the U.S.
