Documentation Skills and the Long-Time EMS Provider

New Tricks

You’ve heard the phrase; “You can’t teach an old dog new tricks.”

Well that may be true about canines, but it certainly isn’t the case with us humans. It’s especially not the case with EMS providers.

Documentation Skills and the Long-Time EMS ProviderLong-time EMS providers should have learned a long time ago that as soon as we learn something new in EMS, it will change tomorrow.

Just like the equipment we use and the skills we employ have changed so has the way we document our runs and we must change with the times.

“I’ve always done it this way…”

We hear this phrase a lot in the billing office when we challenge people to improve their documentation skills. “I’ve always done it this way. It’s worked for me so far. Why do I need to change? Who says I have to do it any different?”

Or, our favorite line is; “That’s the billing company’s problem. They aren’t going to tell me what to do after all these years.”

We understand. There was that day the computer thing showed up in the ambulance and turned everything upside down. “Why do I need a mobile device to obtain the patient’s signature? What was wrong with the paper signature forms we have used forever? Why do I have to use those pull down menus?”

Why? Well, because times have changed.

Johnny and Roy aren’t running around in a little red Dodge squad truck anymore because we’ve learned the benefit of having a MICU on the street. We can now data transfer 12-lead EKG results digitally and there’s no little flip antenna thingy either!

If you’ve been on the street doing EMS for a long time then you’ve seen many changes come and go. Why should we then think that we can document and collect patient information the same way we’ve always done it too?

Getting paid is important. The rules have changed to justify getting paid. So…we have to change the way we document in order to follow those new rules!

Holding our feet to the fire

Claims are being denied and ambulance companies are scrambling to pay the bills.

The Medicare trust fund is running out of money they tell us. The Affordable Care Act (“Obamacare”) is changing the way the Medicaid program works and payments are being scrutinized more than ever.

The result of all of this is the ambulance billing office must work harder than ever to justify collecting payments on behalf of your EMS agency. The sole determinant to whether or not your EMS agency collects dollars to cover the costs of providing that ambulance service rests in the street provider’s hands starting with the Patient Care Report you turn in to document the scenario.

It’s time!

It’s time that all of us EMS providers who have been around for more years that we care to admit, take a good look the quality of the PCR product we’re submitting to the billing office for payment.

Detail is important. Contrast how you handled patient care in the first year or two of your EMS career and compare it to how you do things now. We’ll bet our next paycheck that you are more caring, more attentive and more aware of the things going on around you when part of an EMS scene. You’ve grown up.

So, why not focus on putting what you do down on paper in a more effective way? We know that you are passionate about what you do.

Kick it up…

It’s time to kick it up a notch when it comes to documentation.

If you don’t know how to use a computer, take a class or two. Make an attempt to understand the technology we use in today’s modern EMS. Given all the existing technology there is no reason why EMS documentation can’t be prepared and submitted to the billing office in the shortest window of time between patient care and time to bill.

Pay attention to detail. Learn how to paint a word picture about your EMS scenario using clear clinical documentation. We have tools today that provide us with numbers, values and readings. Use them and record their findings. Sometimes this whole issue boils down to documenting more versus not documenting enough. It may just require you to spend a few more minutes evaluating each PCR you write to make sure you don’t miss anything.

Need to brush up on your writing? Take a class…heck, you can even do that online. The tools are there to help you grow if you think you are lacking some necessary personal skills.

Kick your documentation into overdrive and the enrichment to you personally coupled with the benefit to your EMS agency will further cement your place in EMS history. It’s up to you!

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