The Drama of Documenting Trauma

Making you sweat?

Do traumatic incidents make you sweat? Probably.

Does documenting traumatic incidents make you sweat more? Most likely.

The sheer amount of “stuff” that surrounds our trauma calls many times overwhelms us.

The very nature of the run- auto crashes, industrial accidents, severe falls with complications or the like involving all types of complications- causes our hearts to race a little faster and our brains to go into overload mode.

After the run’s concluded, the fun starts as you begin to compile all those hastily written notes together with bits and pieces of your memory to paint a picture in words about the incident.

It’s not Medicare…

“So, Enhanced,” you ask, “Why cover trauma documentation when all we’re worried about is satisfying Medicare or Medicaid with our documentation and trauma calls aren’t billed to either one?”

Good question!

The Enhanced answer is…

  1. Documentation goes beyond just billing to Medicare. While we worry about Medicare and medical necessity, a lot, we also have to satisfy the requirements of all the other insurance payers as they are considering paying for our transport incident.
  2. Liability, especially auto, insurance has limits. If those limits are reached then who’s gonna pay the bill? Well, if the patient has Medicare or Medicaid, then Medicare or Medicaid as the health insurance they will be in line to pay. Just because the initial accident is trauma-related doesn’t necessarily mean that Medicare or Medicaid will forego their medical necessity documentation rules when you submit a claim to Medicare following the exhaustion or the denial of a liability claim for legitimate reasons.
  3. Think beyond billing. Is there a possibility you may be called to testify in a liability lawsuit court case? Would your documentation adequate describe the trauma scenario to the point that it would a) bail you out of a jam if your care is called into question or b) assist the court in making a liability determination based on the accurate account of the events surrounding your care

The 3 Parts of Documenting a Trauma Call

In our minds there are three basic parts of documenting a trauma scenario. Those parts include descriptions of…

  • The Scene
  • The Patient’s Condition
  • The Treatment and Transport

Documenting the Scene

Because a key element of any trauma documentation is recording the mechanism for the injury, it is important to adequate describe the scene. There are so many examples we can provide but we’ll just name a few of them.

For example, probably the most frequent trauma scene most EMS providers encounter is the Motor Vehicle Accident (MVA) scene. Of course, everything ranging from dispatch to cooperating units, first responders on the scene, weather conditions, road conditions, location of vehicle, damage intrusion, confinement or entrapment presence, location and relation of vehicles to one another, seating position of the patient, use of active and/or passive restraints… all this must and should be included in one way or the other to describe the scene.

Move to industrial accidents and you have a whole new realm of possibilities to record.

In these scenarios consider documenting the type of industry, presence and inclusion of heavy machinery, position patient was found, treatment that may have preceded EMS arrival, nature and severity of the injury, overall mechanism, type of injury (mechanical, electrical, thermal, inhalation such as in gases or chemical involvement, etc.), are there multiple victims including explanation of similar signs and symptoms amongst persons you are treating? Also, we recommend you describe the precautions you had to take to protect yourself and other first responders who are part of the incident.

These are the “big” incidents, but quite frankly even a fall in a household setting qualifies as a traumatic injury event. Consider how you are describing those scenarios. Such as describing the fall from the position, height of the fall, nature of the fall, contributing factors, even down to describing the surface the patient fell from and feel onto (For example, “Patient fell from the top rung of a six-foot ladder onto a plush carpeted floor and suffered a neck injury.”)

Patient Condition

It’s interesting that beyond liability insurance guildelines even the Medicare billing guides and Local Coverage Determinations released by Medicare include CMS and MAC expectations for conditions, comments and examples they will expect to see associated with trauma.

Most billing-related instructions we read begin with some mention of documenting Field Triage when the discussion turns to traumatic injuries. These guides reference the American College of Surgeons, Committee on Trauma (ACS-COT) Field Triage Decision Scheme as the baseline for determining scene conditions which are then later documented to support the protocol used in the response, treatment and the eventual transport (or no transport, depending) of affected patients.

Of course, level of consciousness and severity of injury documentation is critical, however always remember that we must insert values into our documentation wherever possible and especially for these high octane incidents.

Remember to document Glasgow Coma Scale determinations. Severe and life-threatening traumas will obviously point to GCS readings well below the normal 15 and patients with a GCS less than 14 will manifest all sorts of internal and external complications that must be explained. Don’t forget the basics such as Blood Pressure readings and/or respiratory rates.

How about the injuries themselves giving life to your PCR as you document penetrating injuries, injuries to the extremities and quite possibly with deformities which must be explained? Chest injuries can be documentation challenges as can pelvic injuries because of the internal nature of the internal possibilities that existed during your incident.

Those nasty head injuries carry a whole new set of variables, most notably a description of the level of conscious or lack thereof. And there are elements that you have assessed that must be recorded such as pupil reactivity and size, absence or presence of hemorrhaging or draining from eyes, ears or nose, deformities, open wounds, signs and symptoms of closed head injuries and on and on.

We could write an entire book on just the various types of traumatic incidents we encounter but we think you get the point.

Treatment… and Transport

To close out this discussion, be sure to conclude in sufficient detail the treatment of the patient and whether or not the patient was transported.

To document transport, you’ll need to explain the rationale for the patient’s being transported by your ambulance versus the patient’s deciding not to opt for treatment and/or transport to the hospital.

Your treatments must be explained in great detail. Here’s where most ePCR software programs come in handy as they typically will force you to employ a timeline of events when explaining your incident. Chances are, you’re going to need to explain multiple treatments you performed.

Don’t forget to explain how you moved and extricated the patient from the scene. Were there other first responder agencies assisting at the scene? For example “Medic 29 responded along with Rescue 5 and assisted EMS at the scene of a fall over a steep embankment. Rope rescue was employed due to the patient’s suffering bilateral lower extremity fractures. Patient was placed in a stokes basket completely immobilized using a cervical collar, long spine board and CID blocks in place before the patient was carried to safety.”

Make special note if care is transferred to another care provider, such as in a mass casualty incident or an incident where care if provided but ultimately the patient’s condition warranted another mode of transportation to the hospital. The most common for this type of scenario would be Air Medical Transportation.

To help the billing office, when documenting Air Medical involvement be sure to include documentation identifying the air medical transport service used, the location of the landing zone (complete with Zip Code of the landing zone) and when possible also make note in the PCR to identify the receiving facility/patient destination for this incident.

Also, there are those times when a patient (such as the result of an MVA) refuses treatment and/or transport following a traumatic mechanism event against the recommendations of the care providers. This can result in a refusal scenario- which is a blog for another day. However, it goes without saying that very detailed documentation is a must for these scenarios whether you bill or not.

We Are The Doctors of Documentation!

We “prescribe” really good detailed documentation will heal many billing ills. If you’re a regular reader of this blog space, then you’ve come to appreciate how we help our clients and their provider staff members to navigate the fine points of effective EMS documentation which then translates into efficient billing practices.

If you’re a current client, please follow this space each week and share this with others in your organization.

If you’re not a current client but wish you were, contact us today so we can help you too.

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