The Ways And Whys Of Documentation

     In the May issue, I wrote about physician's certification statements (PCS) for ambulance transports. In that column, I pointed out that the documentation on those forms often fails to be sufficiently specific, but good documentation is much more than what's written on a PCS form. There are other ways to establish proper documentation, and there are reasons why such documentation should be done.

The Need to Document
     There are at least three reasons why good documentation should be a concern of every EMS administrator, manager, EMT and paramedic: patient care, legal claims and payment justification.

     First of all, and always priority No. 1, is patient care. Quality assurance and medical director reviews of patient care are based on what is on the patient care report. There is no way to improve your or your staff's ability to handle a particular patient issue without knowing what is occurring in the field. Therefore, accurate and complete documentation is vital to the EMT's and paramedic's continued (or improved) success with patients.

     A second reason, and one that cannot be emphasized enough, is potential legal claims. I think of these as not actual patient care issues, but perceived patient care issues. You may have done every procedure necessary and each may have been done properly; however, if you have not documented it at the time, then it may be difficult or even impossible for you to recreate your care of a particular patient. Even if you have the opportunity to recreate the events surrounding a specific call, your memory may not allow you to. That is why good documentation at the time, when events are fresh in your memory, is crucial. You do not want to be on a witness stand without a good patient care report to fall back on.

     Finally, there are payment issues. For purposes of payment, not documented means not done when it comes to Medicare or Medicaid review of your transports. And not done means not paid. Putting patient care first is all well and good, but the reality is that documenting it well is the only way you are going to get paid for your services. And without payment, most EMS systems will not have the budget for all of the things that really make your job successful.

How to Document
     Now that we know why good documentation is necessary, what are the ways in which we can make sure good documentation is gathered?

     Obviously, the first is detailed and accurate patient care reporting in the field, which has been the focus of the reasons to document that I have already outlined. Good patient documentation is accomplished by a clear (and legible) statement of the patient's condition, specific justification for the medical necessity of any and all services required, and identification of each and every service actually rendered.

     There are also other ways an ambulance service or EMS system can document in order to protect not only their patients, but also their company and their finances. Well-documented personnel policies, administrative procedures and actions taken in response to deficiencies or identified problems are all helpful in dealing with employee issues. These types of records can also help in response to lawsuits alleging negligence, harassment, discrimination and even employee injuries. Keeping written records of correspondence with Medicare carriers or other insurance programs and companies is often necessary to show that you were acting in good faith in trying to follow the guidance you received from these entities. Believe it or not, they do not always admit to or remember having conversations with ambulance suppliers; sometimes, they do not even acknowledge the existence of their own written policy. So keeping good written records of such conversations and policies is often very beneficial to your financial future.

     Documentation is certainly not the most exciting of tasks in the EMS industry, but it may be the most important. The ways require time and diligence, but the whys are certainly compelling enough to justify the effort required to do it right.

     Questions or comments on this column, as well as ideas for new topics, can be sent to Nancy.Perry@cygnusb2b.com.

     This article is not intended to be legal advice. For more information or specific questions, Chris can be reached at chris@emscltd.com, or by calling 800/342-5460.

G. Christopher Kelly is an attorney practicing in Atlanta, GA. Chris focuses on federal laws and regulations as they relate to the healthcare industry and specifically to the ambulance industry. He also lectures and advises ambulance company clients across the U.S. Contact him at chris@emscltd.com.

Chris Kelly is a featured speaker at EMS EXPO, October 11-13, in Orlando, FL. For more information, visit www.emsexpo2007.com.