Winter Flu Season- How to Document?
Welcome Back!
We trust that you had a wonderful holiday season filled with many warm memories.
We’re back to our normal routine so let’s dig into a direct documentation topic…. How to document transports that are initiated either directly or indirectly due to the effects of influenza.
The Flu!
It’s winter. Especially for those clients we serve in the coldest parts of our Country, flu season ushers in a whole new set of treatment and transportation possibilities. Since this is a blog about all things ambulance billing, let’s take a minute to think about how we can effectively document when we transport persons affected by the flu bug.
Do flu patients need an ambulance?
That’s a good question!
On the surface and in contrast to the many severe emergencies we all handle on a regular basis, we seem to think about influenza as being not so bad. But think again.
According to government’s Centers for Disease Control and Prevention, so far this year six percent of all deaths reported across 122 major U.S. Cities were due to Pneumonia and Influenza (P&I).
Just between October 1st and December 6th of this year, the government reports 1,028 laboratory-confirmed influenza association hospitalizations with the highest rate of hospitalization among adults 65 years of age and older followed by children between the age of birth and 4 years old. Seven pediatric deaths have been attributed to the flu in 2014.
So, the answer to our question is…maybe.
The Facts
Now that we’ve established that there may be those patients who really need an ambulance due to the effects of the flu, let’s brainstorm how we should be documenting these transports to paint the picture in words about our scenario in order to justify being reimbursed.
To get started we remind all of you that we must describe the patient’s medical condition in sufficient detail to indicate why transportation by any other means other than an ambulance vehicle was contraindicated for your patient.
Your task is to describe the patient’s condition in full, including your assessments and the numbers and values derived from that assessment. In the back of your mind, you must always direct your documentation to describe if the patient would or would not have suffered negatively by being transported by any other vehicle other than an ambulance.
Since the older members of our patient population are often found by us in some kind of extended care facility, it is also important to document why the patient could not be adequately treated for influenza-associated signs and symptoms at the facility.
In short, was the trip reasonable in nature?
Documenting the Hands-On “Stuff”
So let’s brainstorm all the “stuff” we’ll see connected to flu patients and how we can document it all.
Respiratory Complications
Of course, with a fair amount of flu patients the influenza morphs into a respiratory situation sometimes resulting in the patient’s contracting pneumonia. For the oldest and the youngest of our patient population, this can be a life-threatening event.
So naturally we can think of our need to document…
- Lung sounds (for patients in extended care facilities, we must also document how our treatment was needed beyond the treatment that cannot be provided at the facility)
- Pulse-Oximeter Readings
- Oxygen Delivery (delivery rates, delivery device, treatments- medications by inhalation, injection, infusion)
- Need for suctioning
- Use of positive pressure devices
- Coughing and sputum observations
Dehydration and Fevers
If dehydration or even possible sepsis is a factor as an extension of the flu condition, then consider documenting things like…
- Skin assessments – color, texture, feel (warm, hot, cold, etc.)
- Severely elevated body temperature readings
Nausea/Vomiting/Diarrhea
What if nausea, vomiting and or diarrhea are part of your scenario? Then include findings such as…
- Duration/Onset
- Color and consistency of the solids and/or fluids expelled
- Volume expelled compared to fluid intake as verbalized by the patient or someone in the know
Compromises and Secondary Systems Involvement
Does your patient have a chronic underlying condition that the flu now is exacerbating? If so, be sure to document those complications. There are times when we focus so much on the apparent that we can forget to include the spillover affect into other areas.
So, if there is any secondary compromise such as cardiac or general systems compromise, be sure to include those findings in your Patient Care Report.
- What did the cardiac monitor tell you about your patient?
- Was there any kind of neurological compromise that is negatively affecting your patient?
- What did you do to counteract the negative secondary symptoms?
The Basics
Naturally, never forget the basics.
Always document…
- Vital signs
- GCS
- Level of Conscious
- Mental Status that varies from the patient’s baseline
- Result of critical labs prior to EMS activation (however, negative values alone, minus signs and symptoms of a serious illness event will not constitute justification for payment)
- Any associated pain (include a pain rating on a 1-10 scale, as you normally would do)
Accuracy and the Truth
Finally, we always want to remind the folks in the field to document with enough detail to be accurate and to be truthful. A good EMS billing office should be able to use documentation that is well-prepared and truthful to determine if the transport was provided for a medically necessary patient and to indicate if the trip was reasonable.
