The Art of Constructing a Clinical Narrative

Transcription

1 The Art of Constructing a Clinical Narrative Presented by Douglas M. Wolfberg E. Trindle Road, Suite 202 Mechanicsburg, PA (fax) dwolfberg@pwwemslaw.com Disclaimer: These seminar materials are designed to provide an overview of general legal principles and should not be relied on as legal advice. You should seek advice from an attorney if you have particular factual situations related to the materials presented here. COPYRIGHT 2017, PAGE, WOLFBERG & WIRTH, LLC. ALL RIGHTS RESERVED. REPRODUCTION BY ANY MEANS EXPRESSLY PROHIBITED WITHOUT THE WRITTEN CONSENT OF PAGE, WOLFBERG & WIRTH, LLC.

2 2017 Douglas M. Wolfberg Attorney and Consultant Contact Information Direct Dial: (717) Education Undergraduate: B.S., Health Planning and Administration The Pennsylvania State University Law School: J.D., Magna Cum Laude Widener University School of Law Admissions to Practice Commonwealth of Pennsylvania State of New York Supreme Court of the United States U.S. Circuit Court of Appeals, 3 rd Circuit U.S. District Court, M.D. PA U.S. District Court, E.D. PA Professional Philosophy I consider myself very lucky to be able to combine my lifelong passion for EMS with the practice of law. Having gone from EMT to EMS director to EMS attorney and to apply that background to serve an industry I care about very deeply means that I simply love what I do for a living. Doug Wolfberg is a founding member of Page, Wolfberg & Wirth. For over 20 years he has been recognized as one of the nation s most prominent EMS attorneys and consultants. Doug brings a lifelong love of EMS to his work at PWW he answered his first ambulance call in 1978 and has been involved in EMS ever since. Doug became an EMT at age 16, and worked as an EMS provider and educator in numerous EMS systems over the decades. Doug has steadily worked up the ladder in his EMS career. He worked as a county EMS director and then as director of a threecounty regional EMS agency. He later worked for a statewide EMS council and then went to the nation s capital to work at the United States Department of Health and Human Services, where he worked on federal EMS and trauma care issues. After graduating law school with high honors, Doug worked for several years as a health law litigator. He then co-founded PWW in 2000 along with Steve Wirth and the late James O. Page. Doug represents public, private and nonprofit EMS agencies, billing companies, technology companies, private equity firms and others involved in providing and financing EMS. His practice focuses on revenue cycle management and compliance, EMS system design and evaluation, privacy and security, business transactions and other areas of EMS law. Doug serves as faculty at Commonwealth Law School and the University of Pittsburgh, and is a member of the Board of Trustees of Widener University. He has also endowed the Douglas M. Wolfberg Scholarship at Commonwealth Law. Doug has been a featured presenter at virtually every major EMS conference in the United States and has authored articles and columns in the industry s best-known publications. In his free time, Doug is an avid bicyclist and musician. Page, Wolfberg & Wirth, LLC 5010 E. Trindle Rd., Ste. 202 Mechanicsburg, PA Fax

3 California Ambulance Association 2017 Annual Convention and Reimbursement Conference The Art of Constructing a Clinical Narrative Copyright Statement The unauthorized reproduction or distribution of this copyrighted work is illegal. Criminal copyright infringement, including infringement without monetary gain, is investigated by the FBI, and is punishable by up to 5 years in federal prison and a fine of $250,000. Disclaimers This information is presented for educational and general information purposes and should not be relied upon as legal advice or definitive statements of the law. Consult applicable laws, regulations and policies for officials statements of the law. Exciting News! No attorney-client relationship is formed by the use of these materials or the participation in this seminar. The user of these materials bears the responsibility for compliance with all applicable laws and regulations. Certified Ambulance Documentation Specialist TM The nation s first and only EMS-specific documentation certification course Specifically designed for EMS practitioners EMTs/paramedics QA personnel Managers/supervisors Compliance and billing staff Certified Ambulance Documentation Specialist TM CADSis offered as a one-day preconference workshop at the conference Hershey, PA October 23, 2017 Las Vegas March 27, 2018 Orlando April 24, 2018 St. Louis June 5, 2018 Page 1

4 Certified Ambulance Documentation Specialist TM You can also bring CADS to your agency! Course can be done on-site for one flat fee Course Structure Lesson 1: EMS Documentation Framework Lesson 2: Clinical Narratives 2A Core Principles of Clinical Narratives 2B Formatting the Clinical Narrative Lesson 3: Documenting Consent, Refusals and Special Situations Lesson 4: Documenting Reimbursement Information Lesson 5: Documenting Medical Necessity Lesson 6: Documenting the Reason for Transport Lesson 7: Signatures What is a Clinical Narrative? A clinical narrative is a first person story written by an EMS provider that describes a specific patient encounter. The clinical narrative allows the EMS provider to describe complex and often disparate facts in a manner that can be easily understood by others. Purpose of Narratives Document the complete story of the call in chronological sequence Capture all relevant information about the patient s condition and treatment What a Good Narrative Should Do Paint a picture What a Good Narrative Should Do Above all, the clinical narrative must be accurate It drives coding and reimbursement It is relied upon by governmental and private payers And misrepresentation or falsification can have severe consequences Both for the individual provider and the EMS agency Page 2

5 What A Narrative Should Not Do Not incident reports Do not use to report information that is not germane to the call or the patient Example: After the transport, when backing the unit into the station, the passenger side mirror was inadvertently knocked off. What A Narrative Should Not Do PCRs should not be used to point the finger at another provider or lay blame on another agency Example: First responders on scene had misapplied the extrication collar and admitted they were unfamiliar with its proper use. What a Narrative Should Not Do It should not be used to boast about the provider s skills or the agency s good work Examples: We responded lights and sirens and beat PD to scene. Dispatched mutual aid since neighboring service never gets out on time Started a 16 gauge because pt was rude What a Narrative Should Not Do It should not purposefully omit information for reimbursement purposes Example: Pt was transferred from bed to stretcher What really happened: Pt met us at the front door with his suitcase in hand and the pt was able to lay down on our stretcher without assistance These are actual excerpts from the crew training manual of an ambulance service in Florida Those excerpts were attached as Exhibit A to a False Claims Lawsuit brought by the Department of Justice against the Ambulance Service in 2016 Page 3

6 Narratives in an Age of epcrs Narratives in an Age of epcrs Constructing a narrative is particularly important now that electronic Patient Care Reports (epcrs) are dominant Check boxes, pick lists and automated processes can give the impression that there s not much left to write in a narrative Reviewers medical professionals are used to writing and reviewing clinical narratives In fact, narratives are even more critical in the modern mass of data that is an epcr Narratives in an Age of epcrs Structured data entry does not support expressiveness and flexibility and it can be difficult to interpret and reconstruct meaning from structured data due to loss of context... Patel, et al., Patients understanding of health and biomedical concepts: relationship to the design of EMR systems. Journal of Biomedical Informatics, 2002 Feb:35(1) Narratives in an Age of epcrs Auto Narrative Generation Check boxes collect data Narratives tell stories Some epcr applications have robust auto-narrative generating capabilities These can be useful adjuncts to writing a narrative But they can never replace human inputs And remember, they are only as complete as the electronic information that is entered Page 4

7 The patient complained of. Pulse was. Blood pressure was /. Template Narratives Another development brought by epcrs is the template narrative Templates can appear to be cut and paste and give the implication that a patient-specific assessment was not performed Template narratives have not been well received by skeptical prosecutors and investigators Regardless of how the PCR is generated, it is always critical to proofread it A Visual Exercise Start by thinking of your narrative in visual terms The PCR is a canvas, your words are the paint A Visual Exercise A non-participant should be able to read the chart and see what the crew saw Descriptive words help to make this process more vivid Page 5

8 Descriptive Words Descriptive Words The use of descriptive words makes a narrative more detailed, objective and accurate Insufficiently Descriptive Pt was non cooperative More Descriptive Pt was highly agitated and hostile when we attempted to ask about past medical history Descriptive Words Descriptive Words Insufficiently Descriptive Altered mental status More Descriptive Pt was lethargic and could be aroused only upon shouting loud verbal commands. Pt is oriented to person and disoriented to time and place. Insufficiently Descriptive Pt gave inappropriate responses More Descriptive Pt told crew to f#ck off and despite repeated and courteous offers by the crew to take the patient to the hospital, the patient steadfastly refused. Examples of Descriptive Words Examples of Descriptive Words General Appearance Emaciated Obese Obvious distress No obvious distress Behavioral Cooperative Uncooperative Angry Calm Upset Combative Anxious Dressings Dry Intact Clean Drainage Wounds Open Closed Red White Black Mental Status Awake Alert/oriented Person, place, time, situation Unresponsive Non-verbal Confused Lethargic Extremity Movement Flexion Extension Flaccid Contracted Gait Limited range of motion Page 6

9 Examples of Descriptive Words Examples of Descriptive Words Heart Rate/Pulses Regular Irregular Strong Weak Diminished Bounding Skin Rash Discolored Cyanotic Flushed Mottled Lesions Bruised Ulcerated Breathing/Respirations Airway patent/obstructed Spontaneous Assisted Apnea Labored Shallow Deep Snoring Gasping Symmetrical chest rise Abdomen Enlarged Distended Protruding Rigid Tender Soft/relaxed Quantities Profuse Copious Excessive Moderate Slight Seven Principles of a Good Narrative Principles of a Good Narrative Complete Objective Specific Dispassionate Consistent Professional Chronological Complete Be Complete! Contains all relevant information Does not purposefully omit relevant information Captures all aspects of operations, assessment, treatment, transport and patient disposition Incomplete: Pt was found supine in bed More Complete : Pt was found in a hospital bed in the bedroom, supine, 30 upright calmly speaking to his son, skin pale but in no obvious distress. On oxygen 2 LPM nasal cannula. Pt was unable to get up from bed without assistance and could not be transported by other means due to severe sacral wound to L buttocks Stage 4 per visiting nurse at home. Pt had to be sheet pulled onto stretcher by four personnel and was unable to offer any assistance. Pt very weak and has frequent syncopal episodes when sitting up Page 7

10 Objective vs. Subjective Objective Documentation should be objective, not subjective Objective -Facts -Unbiased Subjective -Opinion -Unsupported conclusions Examples Subjective: Pt appears to be intoxicated at the present time. Objective: Pt has noticeable odor of alcoholic beverages on breath. Pt s speech is slurred and pt admits drinking 6 beers in the past 30 minutes. Objective The patient may report subjective information, but the fact that the patient reports it makes it objective It s a fact of what the patient reported Example: Pt states that it feels like an elephant is sitting on his chest Objective Whenever possible, be quantitative as well as qualitative Quantitative: Specific numbers or values Qualitative Fact-based descriptions Pt describes the pain as sharp and stabbing. Pt rates pain an 8 on a 1-10 scale. Qualitative Quantitative Page 8

11 A Good Narrative is Specific Specificity This is more critical than ever with the implementation of new diagnosis codes (ICD-10) that are required on all ambulance claims This requires more precision both in terms of anatomic landmarks and geographic locations Inadequate Pt was found in bed and transferred from bed to stretcher Examples: Specificity Specific Pt was found in hospital bed in Room 206 in supine position unresponsive to voice with arms and legs flaccid. Pt was log rolled onto side and then back onto a sheet. Moved to stretcher via a sheet pull method by 4 people and secured in a supine position on the stretcher with four cot straps. Pt remained unresponsive to voice during transport Inadequate Patient fell, complains of pain in right shoulder Examples: Specificity Specific Patient was at work at an industrial warehouse when patient fell from a forklift moving at approximately 1mph. Patient has noticeable abrasions and red skin on right anterior shoulder area as well as right posterior scapular area, approximately 2 from top of shoulder. Inadequate Pt has decubitus ulcer on R buttocks Examples: Specificity Specific Pt has approx. 4 decubitus ulcer on right side upper of buttocks, located approximately ½ distally from sacrum. According to SNF staff, wound is Stage 3 and pt experiences severe pain on movement, making it impossible for pt to sit in a chair or wheelchair. A Good Narrative is Dispassionate Page 9

12 Dispassionate Dispassionate means that your chart is not influenced by emotion, bias or personal feelings A PCR is not the place to let life s frustrations bubble to the surface Dispassionate? Dispatched by 911 for SOB at 03:00. AOS to find a 75 y/o female shuffling around kitchen with absolutely no complaints. Pt. says she has a cardiac history and was SOB earlier in the day, but feels fine now. Pt did not need an ambulance, no way, no how. This was a waste of my time. Walked pt to stretcher and transported to ABC Medical Center, transport uneventful Consistent Ensure your PCR does not contain inconsistencies In the narrative itself Between the narrative and the data portions of the PCR With other accurate clinical documentation regarding the patient s condition on the date of service Example: Inconsistent Mobility Status Pt is bed confined. Pt was in her wheelchair when she slipped and fell trying to get up Example: Inconsistent Anatomical Assessment Example: Inconsistent Mental Status Patient is A & O x 4 with GCS of 6 Page 10

13 Professional Accurate and appropriate terminology suitable for your scope of practice Grammatically correct Proper spelling Proper syntax DON T USE ALL CAPS! Terminology It is time for EMTs and medics to brush off their old anatomy, physiology and terminology notes and use them! PCRs must be presented in an objective, clinical manner to: -Support coding -Obtain legitimate reimbursement -Ensure compliance -Reduce liability Compare Documenting Within Scope of Practice Pt has possible broken leg Pt has possible fracture of right distal tib/fib, approximately 5 above ankle, located anteriorly. Lower leg angulated at approximately 40 o It is common for BLS and ALS providers to work together in providing patient care In some instances, such as paramedic intercepts, EMTs and medics may produce separate PCRs Providers should be careful to document within their scope of practice Compare These BLS PCRs Spelling and Grammar Paramedic Smith applied a cardiac monitor. Within the BLS scope of practice Paramedic Smith applied a 12-lead cardiac monitor, which showed sinus rhythm with occasional PVCs Outside the BLS scope of practice Nothing makes a PCR seem less professional and the providers less competent than misspelled words and poor grammar Page 11

14 Abbreviations When using abbreviations, it is important only to utilize those that are commonly understood and accepted No home grown abbreviations Syntax Syntax refers to the arrangement of words and phrases to create complete and well-formed sentences Example - Syntax Chronological Patient cannot completely raise right arm. Or right hand due to pain. Patient cannot completely raise right arm and cannot raise right hand at all due to pain. Narrative should flow in sequence DRAATT chronological narrative format DRAATT Chronological Narrative Format Dispatch Response Arrival Assessment Treatment Transport Page 12

15 Dispatch Narrative should begin with nature of the call at time dispatch This is a critical element that determines proper level and type of service Emergency vs. Non-Emergency ALS vs. BLS (ALS Assessment rule) Should include nature and location of the call as well as any response determinants issued by the dispatcher Dispatch Examples: Dispatched Emergency by 911 for chest pains to a residence at 123 Main Street Dispatched 30-D-3 for major trauma at XYZ Industries Response Documenting information about the response mode also is important for liability, reimbursement and compliance This can be done in conjunction with the dispatch documentation but should not be overlooked Response Examples: Responded with lights and sirens Arrival Narrative should document a size-up of the scene Paint the picture as to what the crew encountered, observations that may impact mechanism of injury, overall appearance of scene, etc. Arrived on scene to find a motor vehicle crash with two vehicles involved. Vehicle 1 appeared to be a compact passenger vehicle with 3 visible occupants and Vehicle 2 with one occupant standing outside the vehicle, which was a fuel tanker truck that appeared to be leaking a fluid onto the roadway. Arrival Page 13

16 Arrival Arrived at XYZ Assisted Living Facility, Room 216, to find an elderly male patient, seated in a chair. Patient s eyes were closed and he was receiving supplemental oxygen via nasal cannula, but appeared to be resting comfortably as we entered the room. Assessment Documentation of a thorough patient assessment is a key component of a good clinical narrative A narrative with insufficient documentation of the patient assessment probably means that there was an incomplete assessment Assessment: General Impression Immediate life threats Chief Complaint - identification of the patient s primary problem usually, but not always in their own words Trauma or medical? Assessment: Mental Status AVPU Alert Responds to verbal stimulus Responds to painful stimulus Unresponsive Altered mental status? Airway Patent airway? Snoring, gurgling, crowing, stridor, etc.? Obstruction? Assessment: ABC Breathing Spontaneous respirations? Breath sounds? Chest rise/fall? Difficulty breathing use of accessory muscles, nasal flaring? Circulation Pulse? Normal? Strong? Regular? Major bleeds? Assessment: Focused History & Exam: Trauma Documentation of rapid trauma assessment DCAP-BTLS Deformities Contusions Abrasions Punctures/penetrations Burns Tenderness Lacerations Swelling Page 14

17 Assessment: Focused History & Exam: Trauma Documentation of systems assessment: Head and face Neck Chest Abdomen Pelvis Extremities Back Assessment: Focused History and Exam: Medical Documentation of rapid medical assessment Pertinent past medical history Medications and allergies Baseline vitals Review of body systems Assessment: The SAMPLE History Signs and symptoms Allergies Medications Pertinent past history Last oral intake Events leading up to injury or illness Assessment: Documenting Pain Pain is a very common complaint encountered by EMS practitioners On its own, pain is non-specific and can be subjective Express it in objective, clinical terms Assessment: Documenting Pain The OPQRST approach should be used anytime pain is documented as a clinical finding OPQRST Onset Provocation or palliation Quality Region and radiation Severity Time (history) Page 15

18 Example Constructing an OPQRST Narrative Example Pt reports chest pain which began at approximately 0545 today. Pt was laying in bed when pain began and was not physically active at the time. Pt states that pain is not affected by movement and there is no position that makes it better or worse. Pt describes the pain as achy and hot. Pt reports that pain is located in the center of the chest, approximately 2 below nipple line. Pt rates pain as a 6 on 1-10 scale. Pt reports that pain was intermittent for the first hour then became constant. O P Q R S T Treatment Documenting the clinical interventions provided to the patient is another key component of the clinical narrative But your narrative must do more than merely identify the treatment provided Treatment Treatment narratives should always address three things: Clinical indications for the treatment The treatment/intervention Results of the treatment/intervention In Other Words, Answer These Three Questions: FIRST Why did you do it? SECOND What did you do? THIRD How did it go? Treatment - Examples Due to patient s ashen appearance, shortness of breath and SPO2 of 90% on room air, EMT Jones started pt on oxygen at 6 liters via simple face mask. Following initial application of oxygen, patient reported the SOB had improved. After 5 minutes, reassessed patient and SPO 2 was 94%... Page 16

19 Treatment - Examples Because patient reported pain from the open fracture of the R tib/fib as 9/10, with no relief from immobilization, we administered 2 mg MS via slow IV push. 5 minutes following administration, pt reported moderate improvement of pain as a 7/10. Transport Narrative should document essential facts about the transport and disposition of the patient: Transport mode to destination (lights/sirens, etc.) Description of destination (hospital, SNF, assisted living, etc.) Reason for bypassing closer destination (if applicable) Transport Narrative should document essential facts about the transport and disposition of the patient: Condition of patient upon arrival at destination, including any clinically significant changes from earlier assessments Handoff of care, including identity of person assuming responsibility for care Remember, DRAATT Dispatch Response Arrival Assessment Treatment Transport DRAATT Chronological Narrative Format Visit PWW Visit our EMS Law Website at Page 17