Our Documentation Quiz

Pop Quiz

Regular readers of this space know that we focus a lot on Patient Care Reports and the documentation in those reports. The real purpose of this blog space is to help all of you become better documenters while calling your attention to the rules and regulations that are in place to guide us.

Our Documentation QuizSo we thought it would be a good break to hit you all with a pop quiz. You can share your answers if you wish or not. That’s up to you.

We encourage you to take the time to walk through these two hypothetical scenarios with us and answer the questions to the best of your ability. Then our next post will include our thoughts and invoke discussion about how we think we would proceed if we were in your shoes.

Scenario 1…

Okay, here we go…

It’s the start of your shift and you just finished checking your ambulance to make sure you’re ready to go for the day. Your supervisor walks into the garage area and hands you a call-intake form directing you to respond to your local hospital for a discharge from the inpatient area out to a Skilled Nursing Facility. He tells you that your patient is an 85 year old male patient who is reportedly bedbound and requires ambulance transport to the SNF. A Physicians Certification Statement will be provided to you when you arrive at the pick-up location.

Off you go!

You arrive at the nurse’s station and are handed an envelope with the patient’s information along with a PCS that a doctor has signed and dated. The medical necessity area on the PCS shows that the doctor checked off the “Yes” box in the “bedbound” area for this patient.

You walk down the hallway to the patient’s room and you find him sitting in a wheelchair next to the hospital bed.  The patient looks up at you, smiles and says, “Let’s go!”

Scenario 1 Questions…

  1. Is the patient bedbound?
    1. If you answered “Yes,” explain why? (Is “because the PCS says so” a valid answer?)
    2. If you answer “No,” explain why? (Does your assessment of the patient trump the PCS?)
  2. Is there a potential problem with verifying the medical necessity of your patient given the fact that he is sitting in a wheelchair? Please think through what the problem might be and explain how you’d handle with your documentation.
  3. How will your documentation answer the question; “Can this patient be safely transported in another vehicle other than an ambulance?”
  4. What discussion will you have with the call-intake and/or supervisor once you return from your run?
    1. Should you consider a conversation with your supervisor before you take this run?
      1. If your answer is “Yes” why would you entertain such a conversation?

Scenario 2…

The 9-1-1 center has alerted you to respond to the local grocery market for a fall victim in the produce aisle. While responding, the dispatcher informs you that your patient is a 57 year old female who fell from a standing position and has pain in her left leg and is unable to get up due to the pain, suspecting a possible fracture.

You arrive on scene to find the patient lying on the floor in a puddle of water on the floor. The patient tells you that she was shopping for produce and slipped and fell due to the water on the floor which was there while a maintenance person was mopping up the remains of a smashed watermelon that someone dropped.

The store manager stands next to the patient with a clipboard in hand asking the patient for her personal information while expressing concern for the patient’s condition.

Scenario 2 Questions…

  1. While treating your patient, what questions should you be asking and what information should you be gathering about the patient’s injuries and the mechanism that caused the patient to fall?
    1. What values should you be collecting and documenting to help you include clear clinical documentation in your PCR?
    2. Think about and list all of the parts of your scenario and describe how you will document things like…
      1. Treatment
      2. Packaging
      3. Patient extrication
      4. Other important information
  2. When collecting your patient’s demographic information, is it important to collect the patient’s health insurance information for this scenario?
    1. If you answer “Yes,” please explain why…
    2. If you answer “No,” why would you reason that you should not collect the information?
    3. Other than health insurance information, what other information may be important to obtain from your patient?
  3. Can you benefit from the store manager’s presence?
    1. What information can he potentially provide that will be helpful to you when you document your scenario?

Play Along…

We hope you’d take the time to participate in our little table exercise. Feel free to use this little pop-quiz exercise as part of your crew meetings and/or training sessions. We’d love to hear not only your answers but also your feedback about how this helps you and your fellow providers become better documenters. Join us next post for our discussion about the scenarios.

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