Tips for writing a proper Patient Care Report

Proper documentation can be difficult in the Emergency Medical Services field. Today Patient care reports are used in the billing process and in some cases used in the legal process. As EMS providers we need to understand that if we can properly document our calls that we close the gap on repercussions later. I want to share some helpful tips on how to write a proper patient care report.

Step 1: Detail is a must.

 The first thing to remember is that if you didn’t write it down in your report than it never happened. In our fast paced profession little things get forgotten and it’s key that we remember to write it down on the report. I got used to carrying a little note pad with me so that I could properly document (Time, Procedure Performed, Status of the Patient, and if Patient was accepting of the treatment or not). These little details can make or break a patient care report. And having notes make it easier for me to reference when it comes time to write my report. Never ever write on your gloves, reason being is that they get bodily fluid on them and you throw them away, than what? All your notes are gone.

Step 2: Never say Walked.

Today many Patient Care Reports are used in the billing process, but most insurance companies are finding reasons to deny billing. If a provider states in their report that a patient “walked” to the stretcher than that report is deemed not billable. Sure I understand, I have been on calls that a patient was in extreme pain but still decided that they wanted to assist themselves to the stretcher, being in a state of vulnerability is not normal for a lot of people and many still try to do things for themselves, but how do we properly document this actions to make it not only friendly for insurance companies but also provide a safety net for ourselves. I have found that using the phrase “assisted to the stretcher” is a fine replacement, honestly no EMS provider in their right mind will allow a patient to walk on their own and sit on the stretcher without at least placing a hand on the patient, this phrase is not a lie, it’s an honest statement, and on a legal aspect it’s a helpful one.

Step 3: Why does the patient need an ambulance?

Another point I want cover is the need for ambulance transport. Why were we called to the scene? I have worked in the emergency and non-emergency sectors of this business, I have learned over the years that it always key to place a reasoning in the Patient Care Report, now I know that some of you are sitting their thinking “that’s what the chief complaint section is for” well yes and no, The chief complaint section of the report is where the well, main complaint of the patient goes, but, it still doesn’t give me a good idea as to why the patient need an ambulance for transport. Let me give you an example, let’s say you’re on medic 11, you’re called for difficulty breathing, and you arrive to find your patient obviously short of breath, well we have our chief complaint, but what makes this patient need the ambulance? What do we have that he doesn’t have if he were to take his own car? The answer is, we have access to oxygen, and we are trained to monitor the patient’s airway. Proper documentation of the patients actual needs, has to be placed within the narrative of the report. It may take a little bit of investigative work on your part but, like I said, just think of what we can provide to the patient verses them going on their own and you will have your answer.

Step 4: Make sure it flows

Patient care reports need to flow, almost in chronological order. We need to make the report as easy to read as possible. There are many templates that EMS providers like to use, I was told once from a wiser co-worker, that to write a proper report you need to “tell a story to someone who wasn’t there”.  Understandably that if I were to write a story than I would need a whole lot more room that what I was provided with, but, what he was trying to get across was that I needed to document the important aspects of the call, in detail, like I was telling a story. Sure it took some time to get used to it but it really does work, even when I helped do quality assurance with my stations run reports months later it was like being there all over again, the littlest detail can help you if you’re ever called into court for a deposition. So make sure the report has a system, and make sure you always stick to it. Here is an example of how my reports were written.

1.       Why was my unit called to the scene?

2.       How did I find my patient when I arrived?

3.       What treatments did I perform after my initial assessment of the patient?

4.       How my patient was assisted to the stretcher and why is the patient in need of ambulance transport?

5.       What treatments did I perform once the patient was safely loaded into the ambulance?

6.       How well was the treatment received by the patient?

7.       Document that a radio report was given to the local hospital( if applicable)

8.       Was transport done without incident?

9.       Where was the patient taken after you arrived at the hospital and were they transferred to the facility without incident?

10.   And always document that you signed care of the patient over to a higher certified care provider.

Step 4: Never Lie

If you didn’t perform a treatment than don’t document that you did, the truth always comes out in the end and it is easier to just be truthful when mistakes happen. Remember it’s not the end of the world, but it does need to be addressed. It’s a high stress job, remember little things will always get over looked, but again if they do, then don’t document that you preformed it when you didn’t.

Proper patient care reports take time to master, but follow these steps and you will be right on your way to helping yourself with proper documentation.