As much as providing care on the scene, EMS personnel should give focused attention to the Patient Care Report (PCR) while collecting data real time. It is critical that the PCR contain complete and straightforward content that accurately reflects the patient’s condition at the time. A poorly prepared PCR can affect patient health – especially since the implementation of ICD-10 – and the organization’s financial vitality.
With resources often strained, however, consistently producing informative and readable PCRs is a challenge. Below are some specific steps to better prepare the narrative in your PCRs—whether you prepare them electronically or on paper.
- Organize information. You may feel pressed to prepare and submit your PCR quickly after a call to take on the next one. Before developing your PCR for the just-ended call, however, you should take time to compose yourself and organize the events in a concise and logical structure. Sound formats are the chronological order (introduction, body, and conclusion) and Subjective, Objective, Assessment, Treatment Plan (SOAP). You are telling a story of the call’s unique events, one that you want everyone who reads the PCR to understand.
- Clearly note your decisions. The patient is counting on your experience and judgment to make the correct clinical decision at the scene. In the PCR, you should clearly note the actions, reasons for, and the care you gave to the patient—especially if you chose one form of care over another.
- Review description of the chief complaint. The chief complaint of the PCR should indicate the primary symptom or injury the patient experienced or why EMS was called to the scene. It is not the cause of the symptom or injury.
- Use clear language and recognized terminology. In today’s world of instant communication, we too often use acronyms, emoticons, and gibberish instead of actual words. Because you may know the meaning of what you wrote, you probably assume that everyone who reads the PCR will know too. The PCR should paint an unambiguous and credible picture of the call with your words, and only use medically recognized acronyms. Clarity upfront can help avoid confusion by legal resources or insurance providers later.
- Proofread and edit the PCR carefully. Not everyone likes to review their
own content, but before you submit a PCR, you – and your partner on the
call – should carefully review it for grammar and style errors. A coherent narrative is vital in accurately capturing the patient’s condition at the time, your assessment of it, and what actions you took. You do not want poor word choices or poor sentence structure to create uncertainty or ambiguity. Julie Tetzloff, vice president, McKesson EMS, emphasizes, “As the industry focuses more on the medical necessity surrounding the transport, the more important it is to provide detailed documentation to support the transport.”
In addition to being a thorough analysis of a call’s events, PCR data can be used for clinical audits and strategic planning, research into new skills and services/equipment, and training plan development. Yes, a PCR contains an abundance of data, but preparing it does not have to be an arduous task. You should be organized, thorough, and accurate, and want to put as much attention on a PCR as you do in taking care of patients. A detailed, engaging PCR both helps the patient and reflects well on you and your organization. “The more detailed the information provided in the PCR, the more accurate the billing, which will in turn help optimize reimbursement,” Tetzloff notes.