[KPFARS-Operations] Epidemic Of Open Charts

[lance at 5047.com]

It appears that we are developing a systemic Epidemic of
open/incomplete/unlocked charts.

 

How can we entertain the possibility of carrying Narcan, Aspirin, or any of
the other more advanced EMS Skills if we can't complete documentation on
basic calls.

 

Please read the artical below.

 

Service Incomplete Charts:
<https://www.emscharts.com/pr/incomplete_charts.cfm> 125 

Incomplete Charts by User 


 <https://www.emscharts.com/pr/incomplete_charts.cfm> User

 <https://www.emscharts.com/pr/incomplete_charts.cfm> Number of Charts


Abedi, Shabab

4


Aly, Angie

2


Arouh, Jeffrey

7


Aswani, Harshita

15


Aya, Disha

1


Bacsa, Joseph

15


Baylis, Brian

7


Betancourt, Donna

2


Christian, Joseph

2


Dahl, Cailey

17


Dickerson, Robert

2


Eisen, Lance

1


Evans, Brenda

1


Evans, David

1


Gaston, Julius

4


Ghooray, Prem

6


Goselin, Richard

1


Haj-Ibrahim, Salma

4


Heins, William

21


Hupp, Rebecca

2


Kennedy, William

3


Klein, Jessica

3


Low-Beer, Alfred

60


Low-Beer, Brian

3


Low-Beer, Frank

4


Low-Beer, Kyle

2


Low-Beer, Nickolas

31


Low-Beer, Timothy

7


Matta, Sanjana

22


Montville, Matthew

3


Patel, Jay

3


Qari, Omar

9


Ravi, Sreyas

1


Shetty, Tanay

2


Vallury, Srinivas

21


Villanova, Anne

50


Weis, Daniel

2


Weis, Raymond

8


Weis, Scott

2

 

 <http://www.emsworld.com/magazine/ems/issue/2005/nov> 

Five Good Reasons for Better EMS Documentation

BY DOUGLAS M. WOLFBERG, ESQ., AND STEPHEN R. WIRTH, ESQ. ON NOV 1, 2005

 

Ask many EMS providers, and they'll tell you documentation is one of the
least favorite parts of their job. However, next to patient care, it is one
of the most important things we do. Many providers do not appreciate the
varied and critical purposes served by their patient care documentation.
Some simply see their patient care reports (PCRs) as documents casually
tossed aside or ignored at the emergency department, or evidence that "can
and will be used against them" in a quality improvement review. A full
appreciation for the importance of EMS documentation comes from a deeper
understanding of its uses and applications in five critical areas: clinical,
operational, legal, financial and compliance. 

This article looks at these five purposes of documentation. Not all of these
issues apply to every EMS provider. For instance, some providers work in
systems that do not bill for their services, so the financial aspect of
documentation may not apply. Nevertheless, EMS providers are likely to move
between several jobs during their careers. Thorough documentation skills
must be "portable," so you can remain marketable in the workplace. 

Clinical: For the Record
First and foremost, EMS documentation serves a vital clinical purpose. It is
the record of your assessment and care of patients. It becomes part of the
patient's medical record, both at the receiving facility and within your EMS
organization. EMS PCRs record the role EMS providers played in the continuum
of care for that patient. An accurate record of the care provided in the
field can play a critical role in the subsequent treatment of patients in an
ED, trauma center or other receiving facility. An effective EMS chart
informs subsequent caregivers of the patient's presenting signs and
symptoms, the caregiver's assessment of the patient's condition, attempted
EMS interventions, successful EMS interventions and the patient's response
to those interventions. 

Because PCRs are primarily clinical documents, it is important that EMS
providers furnish their documentation to subsequent caregivers promptly and
efficiently. For instance, ambulance crews may benefit from the information
contained in the first-responder's PCR. Hospital EDs may benefit from the
information in the ambulance PCR. A physical therapist providing subsequent
rehabilitation to an injured patient during their recovery may benefit from
seeing a complete clinical presentation of the patient's injury, from the
time of the incident forward. 

While it is not always possible to provide a copy of a completed PCR to the
next level of provider at the time of service, information vital to that
provider's assumption of care should be communicated. For instance, if a
paramedic administers a medication while en route to the hospital, the ED
physician needs to know that so as not to inadvertently overdose the patient
on more of that medication, or inadvertently administer a drug that could
negatively interact with one given in the field. In some states, EMS laws or
regulations establish specific time frames, such as 24 hours, within which
an ambulance service must provide a full PCR to the hospital. Check your
state law for any such guidelines that apply to you. 

EMS providers sometimes assert that their documentation is ignored by the
hospital or the ED physician, and cite this as a reason to be less complete,
accurate or timely in their documentation. While EMS providers may not
always witness their PCRs being carefully reviewed by an emergency
physician, they should be aware that their documentation becomes part of the
patient's medical record and will be reviewed and scrutinized. 

Stark evidence of the importance of EMS documentation in the continuum of
care can be found in a 2002 court case where the completeness of an
ambulance crew's PCR was the central issue. According to the court's
unpublished decision in DeTarquino vs. the City of Jersey City (NJ), a young
man was involved in an altercation with police officers, subdued and taken
to the police station. The officers subsequently called EMS to the station
because of the patient's apparent injuries. During the course of EMS
treatment and transport, the patient reportedly vomited. However, this fact
was allegedly not documented on the PCR. The receiving facility to which the
patient was transported-a community hospital emergency department-evaluated
and discharged him. The patient was returned to police custody. At the
police station, he subsequently developed a grand mal seizure. EMS was
called again, and this time the patient was transported to a trauma center.
He was later pronounced brain dead, and the cause of death was determined to
be epidural hematoma. 

Following the patient's death, his family brought a lawsuit against, among
others, the ambulance service and the individual EMS providers. Their legal
theory was that the EMS crew was negligent-not in its patient care, but in
its documentation. If, they argued, the EMS crew had documented the fact
that the patient vomited, as the family claimed, the first hospital might
have recognized this as a sign of a potentially serious head injury, and
might not have discharged the patient. The state's court of appeals agreed,
and held that the state EMS Act immunity provisions did not protect
providers from negligent documentation-only from negligence in the actual
performance of patient care. 

While the DeTarquino case is applicable only in New Jersey, it is
instructive on the importance of accurate documentation from the clinical
perspective. It also emphasizes the importance of writing a complete EMS
chart. 

In addition to the clinical uses of EMS documentation in the real-time
rendering of patient care, documentation also serves another vital clinical
purpose: the assessment and improvement of that care in the future.
Documentation is central to quality assessment and improvement activities in
EMS. It is our ethical imperative (as well as our legal duty in most states)
to participate in a QA or QI process so that the effectiveness of our care
can be continuously monitored and improved. 

Legal: CYA
Of course, EMS documentation serves an important legal purpose. In the event
of a lawsuit like the DeTarquino case discussed above or any case alleging
patient care malpractice by EMS providers, your documentation will
invariably be among the first things reviewed. The central issue in a
malpractice case will be whether the EMS providers met the applicable
standard of care. The EMS PCR will be the best record of that fact. It
should also be a contemporaneous record of that fact. This means the PCR
should be written at or as close to the time of the incident as possible,
thus constituting the most timely record of your care. A contemporaneous PCR
is usually more reliable than a provider's memory when sitting on a witness
stand months or years after the fact. 

One of the first things that most plaintiffs' attorneys will do when
assessing a possible malpractice case is to review the documentation of the
potential defendants, including the EMS providers. Most often, this review
will occur in consultation with an expert witness, such as an emergency
physician retained to help guide the attorney through the clinical
appropriateness of the care and documentation. If an EMS chart is thorough,
well-documented and reflective of the appropriate standard of care being
satisfied, a reputable expert witness may well advise the attorney that
there is no viable case to be had against the EMS providers. While it is
often unlikely that a good PCR will "scare away" a plaintiff's lawyer, it is
a possibility, especially when coupled with the hurdle of legal immunity for
acts of ordinary negligence that EMS providers in most states enjoy. 

>From the legal perspective, EMS documentation should also be thought of as
the provider's "substituted memory." In most states, the plaintiff has a
fairly long period of time after the incident to initiate a lawsuit. This
period is set forth in the statute of limitations. While it varies from
state to state, the statute of limitations is most often measured in years
(often two years). Memories can fade quickly though, and recollections of
patients can blend together-especially after a few hundred calls. A
well-written and descriptive PCR that creates a clear picture of the patient
can trigger your memory of other important details of the call that are not
documented on the chart. 

Even if a lawsuit is brought immediately after an incident, it could still
be months or years until the case moves into the discovery phase, where the
EMS provider is likely to be giving a deposition or sitting on a witness
stand. The farther removed we are from the actual event, the harder it
becomes to recall the facts and circumstances of that event. When testifying
months or years later, and trying to demonstrate that your treatment met the
applicable standard of care, your documentation will often be the only thing
you can rely on to help you paint that picture for a judge or jury. 

Because of the importance of the EMS chart as a legal document, it is vital
that the integrity of the PCR be ensured. It is permissible to make late
entries or write an addendum to your chart, but this should, whenever
possible, be done as soon as possible following the incident. The longer
after the incident you make such a change, the more it will look like a
self-serving effort to make the chart look like something you wish had
happened, not something that actually happened. Over time, we often
subconsciously gloss over our mistakes. Documentation recorded long after
the fact can raise many troubling issues when you have to defend yourself on
a witness stand. 

Operational: Data Drivers
Documentation forms the backbone of many operational issues in the delivery
of EMS. For instance, times documented on PCRs (and from other sources, such
as dispatch records or device time clocks) are necessary to track important
performance measurements such as response times, call-to-intervention times,
on-scene times, transport times and other such assessments. 

EMS PCRs also form the basis of most regional and statewide EMS data
collection systems. When aggregated and properly analyzed, field
documentation can help drive many important system decisions, such as those
regarding ambulance deployment, staffing, peak-demand utilization, disaster
response and more. Data based on PCRs is also often used by policy makers at
the regional and state levels to make decisions regarding funding, training
and the allocation of resources. 

The previously reviewed QA/QI uses of EMS documentation are closely related
to another critical operational use: training and continuing education.
Ideally, documentation and the resulting data will help determine where an
EMS organization needs to concentrate its efforts in personnel training,
education and skill evaluation. For instance, if your organization's
documentation reveals that a particular paramedic or group of medics hasn't
performed an intubation in the past three months (or whatever period of time
you happen to use), you may want to offer a practical skills-oriented
continuing education or in-service program on airway management. Or perhaps
you could arrange for those medics to perform a clinical rotation at a local
hospital or spend some time in a simulation lab. 

Financial: The Bottom Line
As many providers know, documentation plays a critical role in billing and
reimbursement. In fact, it is not an overstatement to say that the PCR is
easily the most important document in this process. Even a cursory look at
today's healthcare system tells us that billing and reimbursement are
critical to the survival of almost any entity that provides medical care,
whether it is for-profit, nonprofit or public. 

Perhaps the financial realities of healthcare and EMS can best be summed up
by the phrase "no margin, no mission." This means if we don't pay attention
to our bottom lines, we won't be here to take care of the next person who
needs our assistance. It is therefore incumbent upon every EMS provider (at
least those who work in organizations that bill for their services) to make
sure their documentation is capable of supporting a prompt and accurate
billing decision. To be clear, this is not to say it is the responsibility
of EMS providers to document in a manner that permits their ambulance
service to always get paid. It is, instead, the responsibility of EMS
providers to be complete, accurate and timely in their documentation, so
that a prompt and compliant billing decision can be made. 

Consider, for instance, the Medicare rules regarding medical necessity.
Medicare, which is the single largest payer for most ambulance services
(comprising 35%-50% of the revenues in most EMS organizations that bill for
services), will only pay for ambulance services where other means of
transport are contraindicated by the patient's condition. This is an
exacting criteria-it means Medicare will not pay for ambulance services
unless the patient cannot safely be transported by other means (e.g., car,
bus, wheelchair van). 

Medical necessity is presumed to be met when the patient experiences an
emergency medical condition such as a myocardial infarction, stroke,
fracture, hemorrhage or other serious and emergent condition identified by
Medicare. These conditions deal with medical necessity. However, the level
of Medicare reimbursement for a medically necessary transport is also based
upon how the provider was dispatched. If the EMS dispatch meets Medicare's
criteria for an "emergency" response, the ambulance service can be paid at a
higher emergency rate, even when the patient's condition turns out not to be
an emergency. Therefore, documentation of emergency calls should include the
nature of dispatch, even if the patient's condition on scene turns out to be
different. For instance, "dispatched by 9-1-1 for an ALS emergency for chest
pains. Arrived on scene to find patient complaining of nausea x 2 days." 

Emergencies are one thing, but it is altogether more challenging to meet
Medicare's medical necessity criteria for nonemergency ambulance transports.
Such nonemergency calls include the transport of a patient from a hospital
to a nursing home following discharge, or the scheduled transport of a
patient from a nursing home to a dialysis clinic. 

For nonemergency transports, Medicare requires either that the patient be
bed-confined or that the patient's medical condition prevents safe transport
by other means. To be bed-confined under the Medicare criteria means the
patient is unable to get out of bed without assistance, ambulate and sit in
a chair or wheelchair. From a documentation perspective, it is imperative
that the EMS provider document things like where and how the patient was
found and how the patient got to the ambulance stretcher. For instance, if
the patient was found seated in a chair in her room at a nursing facility,
then walked with assistance to the stretcher, these important facts should
be documented. It is simply not enough to document merely that the "patient
was placed on our stretcher and transported." The PCR must document how the
patient was moved or otherwise conveyed to the stretcher. 

Some ambulance service managers have suggested that if a patient was
observed to be sitting or ambulating, their EMS providers should omit these
facts from their PCRs, since they would not support a finding of medical
necessity and would thus make it more difficult to bill for the transport.
While it is true that a patient who was sitting or ambulating would not meet
the bed-confined criteria, there may still be other reasons that transport
by ambulance is required. It is the responsibility of the EMS provider to
document these reasons. For instance, if a patient was ambulatory to the
stretcher but required upper airway suctioning and oxygen en route to the
facility, these facts would likely support medical necessity. Other reasons
could as well. 

If the patient does not meet the bed-confinement criteria or any other
criteria for medical necessity, it is important that EMS field providers
honestly and accurately document these facts. The willful failure to
document findings that fail to support medical necessity could be just as
illegal as the outright falsification of a chart to dishonestly make a
particular transport billable. If the patient is ambulatory, the PCR should
say so. If the patient did not require oxygen or airway management or pain
control or cardiac monitoring or IV medications or any other therapy, the
PCR should accurately reflect it. If, in the final analysis, the PCR does
not meet the criteria to bill Medicare, at least a prompt decision can be
made in the billing office. In such cases, the bill can be sent to the
patient or the patient's financially responsible party. At least the billing
office staff is not placed in a position of having to guess or assume that
medical necessity was met, and the ambulance service is not faced with a
delay in its cash flow while it attempts to track down enough information to
fill in the gaps on an incomplete PCR. 

>From the financial perspective, EMS documentation must include everything
necessary to making proper billing determinations. For instance, the
patient's signature, or that of an authorized signer on the patient's behalf
(such as the patient's legal guardian or whoever holds their healthcare
power of attorney), in order to assign the patient's benefits directly to
the provider of healthcare services. It could take the billing office days
or even weeks to track down a signature that could have been obtained in
mere moments in the field at the time of service. If a patient cannot sign
because of their condition, the crew should document why the patient is
unable to sign, not merely that they are. 

Compliance: Following the Law
Finally, EMS documentation serves an important role in the overall
compliance of the organization. Compliance in this context essentially means
that the organization is operating in adherence with all applicable
contracts and local, state or federal laws, such as response time standards
or other performance requirements. At the state level, there are typically
minimum staffing and personnel requirements, and compliance with these can
be readily ascertained with reference to your EMS documentation. 

At the federal level, myriad laws and regulations pertain to EMS and
ambulance services, and field documentation is often the best proof of
compliance with them. For instance, OSHA requires the availability and use
of personal protective equipment to prevent exposure to bloodborne
pathogens. HIPAA requires we give most patients privacy notices and make
good-faith efforts to obtain their signed acknowledgment that they received
them. 

Additionally, because Medicare and Medicaid benefits, as well as those paid
through certain other government programs, are public funds, there are a
host of federal laws and regulations that apply to billing for them, and
then to keeping the money once your organization receives it. Medicare
audits are fairly common and usually involve a Medicare carrier or other
government contractor (sometimes a specialized fraud investigator)
retrospectively reviewing an ambulance service's charts, invoices and other
records to ensure that payment was appropriate. These audits and
investigations often compare the EMS documentation to the documentation from
other providers in an attempt to ascertain a more complete picture of the
patient's condition. 

It is not, for example, uncommon for an audit to uncover evidence from a
nursing home chart showing that a patient was ambulatory immediately prior
to being picked up by the ambulance, even though the ambulance crew may only
have observed the patient in bed the entire time. Even though the standard
for reimbursement is bed confinement at the time of transport, Medicare may
use this information from the nursing home chart to retrospectively deny
payment to the ambulance service, requiring that the organization repay any
amounts it received for those services. For this reason, field documentation
should be supplemented with thorough and effective call intake
documentation. Specially trained call intake personnel should obtain
detailed information for nonemergency transport requests prior to the time
of service so that a complete picture of medical necessity can be
documented. 

Conclusion
By understanding the five most critical uses of EMS documentation, EMS
providers can gain a fuller appreciation for the importance of their PCRs.
Hopefully this appreciation will translate into more complete, accurate and
timely charting by EMS providers in both emergency and nonemergency
situations.

 

 

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