Documentation and Tricks of the Trade

Transcription

1 emeds ELITE Documentation and Tricks of the Trade

2 Objectives By the end of the lesson, the provider will be able to: Demonstrate ability to log into emeds Elite Define California Measures and how these measures relate to a patient care report Identify features in emeds Elite, including how to create a downgrade report, import vitals and procedures from the Lifepack, and utilize the auto generate narrative. Define medical necessity and produce a CHART narrative that demonstrates medical necessity Identify importance of properly documenting a patient refusal Create a patient care report utilizing emeds Elite, including a proper CHART narrative

3 Overview Logging in to emeds Elite General information California Measures emeds Elite Overview Tricks of the Trade Reimbursement and Medical Necessity CHART Documentation Refusals Practice

4 Why Are We Here? Elite is an upgrade to the patient care reporting system and is being mandated by MIEMSS. NEMSIS dataset requirements NEMSIS (National Emergency Medical Services Information System) is a national effort to standardize the data collected by EMS agencies. Discuss the interface changes of the new Elite patient care reporting system. Collection of more accurate data Improve information gathering used in the billing process.

5 Logging In Maryland provider number and MIEMSS Licensure password Automatically syncs Forget your password? Elite vs Elite Field Be sure to use www. when accessing Elite via Internet You can also access Elite through the MIEMSS website and click on the Elite link

6 Do I Need to Do a Report? Was an incident number created? Injured firefighters to FROMS or ED Helicopter standbys Downgrade reports

7 Do I Need to Do a Report? Upgrades from ALS providers from other jurisdictions Transporting jurisdiction can bill Write a report form a BLS perspective We can transfer reports between agencies Toughbooks

8 Protocol Updates Our emeds reports will now be linked to CRISP (Chesapeake Regional Information System for our Patients) CRISP is an electronic healthcare information exchange Physicians and others with access to CRISP will be able to view our reports Our reports are part of patient records

9 California Measures Patient Assessment Yes No Facial Droop * Arm Drift/weakness Denies Abnormal Speech/behavior * Time of day patient last seen normal * Headache Denies Seizure Stroke.docx Use of anticoagulants * Contact information for patient historian * Administer oxygen if indicated (Pulse Ox <94%) NA Assess Vital Signs Breathing Rate * Blood Pressure * Blood Sugar Level 150 EtCO2 (If oxygen is administered) NA EKG if ALS * Lung Sounds * Pulse * Pulse Ox * Notify Closest Stroke Center via EMRC radio * Treatment Establish IV/Saline lock * Administer Dextrose if indicated Administer Zofran if indicated Destination Transport begun in less than 15 minutes * 9 Closest Stroke Center and priority * P1 At patient to hospital time <30 minutes * 19 Time from 911 call to hospital <30 minutes * 26

10 California Measures Standardized performance measures or quality indicators Used for examining an EMS system or treating an identified patient condition AKA Quality Indicators or Performance Measures Used as measures of quality for hospital inpatient and outpatient care events

11 California Measures 8 Bundles Trauma Acute Coronary Syndrome/Heart Attack Cardiac Arrest Stroke Respiratory Pain Intervention Pediatric Skill Performance by EMS Providers

12 California Measures TRA-1 Scene time for trauma patients TRA-2 Direct transport to designated trauma center for trauma patients meeting criteria ACS-1 Aspirin administration for chest pain/discomfort rate ACS-2 12 lead ECG performance ACS-3 Scene time for suspected heart attack patients ACS-5 Direct transport to designated STEMI receiving center for suspected patients meeting criteria CAR-2 Out-of-hospital cardiac arrests return of spontaneous circulation STR-2 Glucose testing for suspected acute stroke patients STR-3 Scene time for suspected acute stroke patients RES-2 Beta2 agonist administration for adult patients

13 California Measures PED-1 Pediatric patients with wheezing receiving bronchodilators SKL-1 Endotracheal intubation success rate SKL-2 End-tidal CO2 performed on any successful endotracheal intubation CAR-3 Out of hospital Cardiac Arrest Survival to Emergency Department Discharge CAR-4 Out of hospital Cardiac Arrest Survival to Hospital Discharge PAI-1 Pain intervention STR-5 Direct transport to stroke center for suspected acute stroke patients meeting criteria

14 California Measures Multiple factors impact the validity and analysis of these retrospective data, including but not limited to: incomplete documentation documentation not reflective of services provided prior to ambulance arrival, inconsistent data dictionary definitions between local jurisdictions, geographic resource disparities, and inability to collect hospital outcome data.

15 California Measures Beta-2 Agonist Administration for Adult Patients Primary or Secondary Provider Impression is respiratory distress Patients are 18 years or older Medication administered is any of the allowed Beta-2 specific bronchodilators

16 California Measures

17 California Measures Hypoglycemia Patients receiving treatment to correct their hypoglycemia Glucometer reading <70 will prompt user to enter treatment in Elite (if applicable) Medications under analysis: Glucagon Oral Glucose Dextrose 50% (D50) Dextrose 10% (D10) Dextrose 25% (D25) D5W (Dextrose 55 in Water) D5W with ½ Normal Saline Dextrose 12.5%

18 California Measures

19 California Measures

20 emeds ELITE

21 Cloud and Connectivity As the provider is doing the report in Elite, the information is backing up to the cloud in real time. If the provider loses connectivity, the work the provider is doing is cached locally. Once connectivity is restored, the information the provider input while dark catches up to the cloud. Posting a report moves the information from the cloud to the main database Need a connection to sync, download CAD, or download EKG

22 Medical Consults Be sure to document Medical Consults for patients in the Procedures tab

23 Trauma Decision Tree If you have a true trauma patient you should utilize the Trauma Decision Tree and transport to a Trauma Center If you have an injured person, the Trauma Decision Tree should be Not Applicable

24 Lifepack 15 New transmission site: MC ELITE No cables! Transmit to MC ELITE site and import into the report First ALS provider on scene should transmit to MC ELITE so transporting provider can include initial vitals, EKG, etc. into the report Use the Lifepack to timestamp interventions

25 Tricks of the Trade Update times from CAD after you already started a report Once you download a ticket, times will stop importing into your report Click on the CAD icon again (at the top)

26 Tricks of the Trade My hospital destination is not listed Use Other Facility- 888 When we transport an injured firefighter, an emeds report must be completed This includes transports to FROMS

27 Tricks of the Trade Previous emeds used Disposition to flag required fields. New emeds ELITE also uses At Patient Side to flag required fields. Before starting report, fill in Times- particularly At Patient Side

28 Tricks of the Trade Program will automatically search for a repeat patient in the database as you start to input patient information Searches back 90 days Be sure the patient is the correct patient before you choose from the name from the repeat patient list There is no undo button

29 Tricks of the Trade Documentation left at the hospital We should be choosing Printed Official Hospital Report - not No Documentation Left MIEMSS should be adding Posted in the near future- we will choose that option when it happens

30 Tricks of the Trade Photos can be added directly to report by choosing attachment

31 Tricks of the Trade Chrome is the preferred web browser to use for Elite reports Internet Explorer is the only browser we can currently use for emeds

32 Tricks of the Trade

33 Tricks of the Trade Scanning Driver s Licenses into Elite Use the A2 button to scan the barcode on the driver s license Be sure to return the driver s license to the patient Document this under patient belongings tab

34 Documenting Controlled Substance Administration

35 Documenting Controlled Substance Administration

36 Handtevy

37 Reimbursement and Medical Necessity

38 Reimbursement- Performance Dashboard *Some of the transports processed may never be billed out due to lack of insurance information.

39 Reimbursement- Use of Revenue

40 Reimbursement- Status of Charges by Date of Service

41 Social Security Numbers

42 Social Security Numbers There will be times where we are unable to obtain patient s Social Security Numbers Unable to remember, do not want to give it out, do not have one, etc. Use when unable to obtain patient s Social Security Number

43 Social Security Numbers Whenever possible please obtain patient Social Security Number If provider uses all 9 s, then there is no match made with computer system that marries our epcrs to the hospital intake information that gives the billing contractor insurance information to bill. When we put all 9 s, patients will be sent a request via mail to obtain the information

44 Social Security Numbers When you are unable to obtain a patient Social Security Number, please try and obtain the patient Medical Record Number from their hospital bracelet This can be found under CAD tab

45 Signatures PATIENT CAPABLE OF SIGNING:. TYPE OF PERSON SIGNING SIGNATURE REASON SIGNATURE STATUS PATIENT HIPAA ACKNOWLEDGEMENT/RELEASE AUTHORIZATION/RELEASE FOR BILLING SIGNED EMS PRIMARY CARE PROVIDER (FOR THIS EVENT) REPORT AUTHOR SIGNED HEALTHCARE PROVIDER TRANSFER OF PATIENT CARE SIGNED

46 Signatures PATIENT NOT CAPABLE OF SIGNING: TYPE OF PERSON SIGNING SIGNATURE REASON SIGNATURE STATUS PATIENT HIPAA ACKNOWLEDGEMENT/RELEASE AUTHORIZATION/RELEASE FOR BILLING NOT-SIGNED (REASON) EMS PRIMARY CARE PROVIDER (FOR THIS EVENT) REPORT AUTHOR SIGNED HEALTHCARE PROVIDER TRANSFER OF PATIENT CARE SIGNED EMS PRIMARY CARE PROVIDER (FOR THIS EVENT) OR PATIENT REPRESENTATIVE AUTHORIZATION/RELEASE FOR BILLING SIGNED NOT PATIENT

47 Signatures REMEMBER- Medicare requires patient authorization signatures before the claim can be billed Patient is responsible for the bill if they refuse to sign (Medicare)

48 Medical Necessity What is medical necessity? Medicare defines medical necessity as: Medical necessity is established when the patient s condition is such that the use of any other method of transportation is contraindicated. In any case in which some means of transportation other than an ambulance could be used without endangering the individuals health, whether or not such other transportation is actually available, no payment may be made for ambulance services.

49 Medical Necessity Medicare pays for medically necessary ambulance services when other methods of transportation would endanger the beneficiary s health In your narrative be sure to identify the medical need Pain, bleeding, altered LOC, chest pain, etc.

50 Medical Necessity About 1,800 calls a year have been marked as nonbillable $400,000/ year is lost (about 2% of our total revenue) 25-50%- will always be non- billable ( I can t sleep or I ate too much )

51 Medical Necessity There are call types that we commonly run that are often considered non-billable, which may be billable with better documentation. ETOH Is alcohol masking an issue? What is patient s level of consciousness? Is this an attempt to get off the street Document patient medical history and medications thoroughly Focus on signs and symptoms of patient, the impact of the alcohol on patient condition, any drug use Suicidal patients- considered medically necessary transport

52 Medical Necessity There are call types that we commonly run that are often considered non-billable, which may be billable with better documentation. Motor vehicle collisions In order to be billable, patient should have an injury I am shook up or I want to be checked out just in case is considered a courtesy transport and is non- billable.

53 Medical Necessity There are call types that we commonly run that are often considered non-billable, which may be billable with better documentation. Bad labs Is the patient bed bound or non- ambulatory? Why were the labs done? Why do the bad labs warrant a transport to the ED via ambulance as an emergency transport? Include patient history- especially any cardiac history If possible, attach a copy of the lab report

54 Medical Necessity Not meant to encourage the crew to find something with the patient, but to rule out they are not missing anything. Even though a patient is a frequent flyer, the report should be written as if it is the first report and based on the patient s chief complaint at that time.

55 Medical Necessity Outcome Treated and transported- why? How did patient get to transport unit? If patient walked, why was this necessary or allowed In unit If patient did not ride on stretcher, document why this was preferred method of transport

56 Documentation CHART

57 CHART Documentation 500 epcrs requested each month by patients and their attorneys Hospital physicians are in our reports every single day via emeds website

58 CHART Documentation Top 10 Documentation Errors: 1) Times 2) Vitals 3) Medications 4) Procedures 5) Patient Refusals 6) Pt history 7) Chronology 8) Consistency 9) Unusual Circumstances 10) Abbreviations

59 CHART Documentation The narrative should be well written and thorough Proper grammar and no spelling mistakes Be careful of abbreviations PCR becomes a legal record and part of patient medical record

60 CHART Documentation YES!! NO!! C (Chief Complaint) - l leg tingling and pain. H (History) - Dispatched to a Residential - House/Apartment/Dorm for a 19 year old Female, complaining of Sick Person - MPDC 26. The patient was found A732 AOS TO FIND PT WALKING TO THE UNIT. SHE WAS AAOX3, BUT WORRIED ABOUT WAKING HER PARENTS (SHE IS 19 YO). PT WAS AMBULATORY.. Events prior to the incident: PT SAID HER LEG HAD BEEN TINGLING FOR OVER A WEEK AND COULD FEEL HER PULSE THROUGH HER CALF. PT THINKS SHE MAY HAVE ANXIETY BUT HAS NOT BEEN DIAGNOSED WITH ANYTHING MEDICALLY.. A (Assessment) - VITALS ON RECORD, NOTING OUTSTANDING FOUND. PT SAYS HER LEG WAS TINGLING, MAYBE HURT, FELT HER PULSE IN HER CALF FOR OVER A WEEK. PT WAS VERY ANXIOUS AND CONFUSED. Rx (Rendered Treatment) - PT WAS ASSESSED, TREATE, AND TRANSPORTED TO SGAH PEDIATRICS ON CAPTAINS CHAIR USING SAFETY BELT. PT THEN BROUGHT INTO FACILITY ON A WHEEL CHAIR. ALL BELONGINGS LEFT WITH PT, PROPERLY TRANSFERRED TO ED STAFF. T (Transport) - The patient was transported No Lights or Sirens. The patient PT WAS VERY ANXIOUS THROUGHOUT TRANSPORT, VITALS REMAINED STABLE THROUGHOUT TRANSFER TO ED FOR SCENE.. D (Destination) - The patient was transported to Shady Grove Adventist Hospital The destination was determined by Patient Choice.

61 CHART Documentation Good documentation strategies Complete information Assure and record accurate data and time Attach any supporting documents or attachments (EKGs, photographs, medication lists, etc.)

62 CHART Documentation Narrative Should be a detailed picture of the patient and the incident in your words

63 CHART Documentation C- CHIEF COMPLAINT What the patient/ family/ healthcare professional tells you is the current issue (why 911 was called)

64 CHART Documentation H- HISTORY Be sure to include the history of the present illness (HPI) and the patient s past medical history (PMH) Include information about smoking, obesity, other risk factors OPQRST, SAMPLE, etc. Any statements made about the current incident and past pertinent events

65 CHART Documentation A- ASSESSMENT How you found the patient upon your arrival Primary survey ABCDE Secondary survey Head to toe exam Positive and negative findings Pt c/o pain upon palpation Pt denies headache Results of any assessment/ diagnostic tools Blood glucose EKG/ 12 leads Capnography

66 CHART Documentation R- TREATMENT All treatments and interventions Watch time stamps! Document patient response to interventions

67 CHART Documentation T- TRANSPORT/TREATMENT Any changes in patient s condition Transfer of care Don t forget to get first and last name of nurse/ physician and degree with your signature

68 CHART Documentation C (Chief Complaint)- My chest hurts.

69 CHART Documentation H (History)- Pt states that an hour ago he was sitting in his recliner watching television when he suddenly developed chest pain in the center of his chest with radiation to his left arm and to his back. Pt describes pain as a constant, crushing pain and it feels like an elephant is sitting on his chest. Pt states the pain is a 9 out of 10 on pain scale. Patient also c/o nausea but denies vomiting at this time. Pt denies SOB/TB. Pt states that he took 324mg ASA prior to EMS arrival as suggested by 911 call taker.

70 CHART Documentation H (History)- continued Pt medications- Lopressor, ASA (81mg)- pt is compliant with medications. PMH includes HTN, MI in 2000 and three stents placed in Pt states that this pain is similar to the pain he had when he had his MI in Pt denies diabetes. Pt denies smoking tobacco products. Pt is obese- weight approx. 300 pounds.

71 CHART Documentation A (Assessment)- pt alert x 4 upon EMS arrival. Pt denies LOC. Pt denies SOB. Pt c/o CP. Pt is in obvious distress. Pt continues to complain of constant pain in center of his chest. Serial EKG/12 leads- sinus tach with ST elevation noted in leads V3, V4, V5. Pt denies increase in chest pain upon palpation. Pt skin- pale, diaphoretic, warm. Pt continues to deny SOB. Pt O2 sat on room air is 90%. Pt placed on O2 via 4 LPM with improved O2 sat to 96%. ETCO2 monitored- 33. Lungs are clear and equal bilaterally with good air movement. Resp rate- 14/ minute. Pt able to speak in full sentences. No edema noted in extremities.

72 CHART Documentation A (Assessment)- continued Pt continues to complain of nausea. Abdomen is soft and nontender upon palpation in all quadrants. PERRL. Pt answers all questions and follows commands appropriately. Pt denies headache. No facial drooping, slurred speech, or unilateral weakness noted. Pt has good ROM of all extremities. Pt initial b/p- 136/98. Pt denies other complaints at this time.

73 CHART Documentation R (Treatment)- pt assessment, vitals, serial EKG/12 leads- sinus tach at rate of 120/ min with ST elevation in leads V3, V4, V5 and reciprocal changes noted. 12 lead successfully transmitted to SGAH. O2 via 4 LPM administered with improved O2 sat to 96%. Pt self administered ASA 324mg prior to EMS arrival. IV est with 16 gauge in left AC with 100cc LR administered KVO. Pt administered 0.4mg SL x 3 with no pain relief. Consulted with SGAH via EMRC- priority 1 STEMI alert. Advised by Dr. Attitude to administer 75mcg Fentanyl IVP as needed for pain relief. Pt moved to cot via 6 person lift and transported in high Fowler s position.

74 CHART Documentation T- (Transport)- Administered 75mcg Fentanyl slow IVP- pt states pain has decreased from 9 out of 10 to a 5 out of 10. Pt condition and vitals monitored en route to SGAH. Serial EKG/ 12 leads performed en route. No other changes in pt condition noted. Pt transferred to room 6- care transferred to Tina Sassy, RN.

75 CHART Documentation

76 CHART Documentation Auto Generate Narratives Use CHARTD format (or SOAP) Takes information from your entries and creates a narrative Fill in the blanks to create a picture

77 CHART Documentation C (Chief Complaint) - DOA. H (History) - Dispatched to a Building/Premises - Retail Store (not in enclosed mall) for a 49 year old Male, complaining of Unknown Problem/Man Down - MPDC 32. A (Assessment) - - Rx (Rendered Treatment) - T (Transport) - D (Destination) -

78 CHART Documentation C (Chief Complaint) - ANXIETY / DEPRESSION. H (History) - Dispatched to a Residential - Assisted Living Facility for a 69 year old Female, weight approx kg, complaining of Chest Pain - MPDC 10. The patient was found IN HER ROOM. Events prior to the incident: PT FEELS VERY ANXIOUS AND SAYS IT USUALLY HAPPENS EVERYTIME HER DAUGHTER VISITS AND THEN LEAVES.. A (Assessment) - - PT WAS HAVING AN ANXIETY ATTACK AND HAS A HISTORY OF ANXIETY AND DEPRESSION. PT WAS ASSESSED AND PREPARED FOR TX TO THE HOSPITAL. Rx (Rendered Treatment) - PT WAS PLACED IN POSITION OF COMFORT AND TX TO HOLY CROSS HOSPITAL WITHOUT INCIDENT. T (Transport) - The patient was transported No Lights or Sirens. The patient PT HAS A HISTORY OF ANXIETY AND DEPRESSION AND WAS HAVING AN ANXIETY ATTACK. PT HAS NOT TAKEN MEDICATION FOR HER CONDITION IN AWHILE.. D (Destination) - The patient was transported to Holy Cross Germantown Hospital The destination was determined by Closest Facility.

79 CHART Documentation M7xx AOS to find a female pt walking out to F/R from her apartment. Pt was in minor condition. Pt had a patient airway without intervention and was conscious and alert. CC: back pain HPI: Pt. started having this problem today. Pt stated that she woke up with back pain. Pt stated she believes her pain is from a bad bed. PE: Head: No abnormalities noted. Airway: Pt. was able to maintain an airway on their own without provider intervention. Neck: No abnormalities noted. Neuro: CAOx4. (Person, Place, Time, Event). Pt. was responsive to verbal stimuli. Pt. had a GCS of 15 throughout care and transport. Pt did not complain of a headache, dizziness or an altered LOC. Eyes: PERRL. (Pupils Equal, Round, and Reactive to Light). Ears: No abnormalities noted. Pt. had no difficulty hearing providers speak to them. Chest: No physical abnormalities; no flail segments, bruising, or tenderness upon evaluation/palpation. Back: No abnormalities noted. Pt. did complain of new back pain. Lungs: Clear and equal, bilaterally. Normal tidal volume with respirations, with a respiratory rate within normal parameters. No wheezing or stridor noted. Abdomen: No abnormalities noted. Soft, non-tender with no rigidity or distention. Pt denied any nausea or vomiting. Pelvis: No abnormalities noted. Extremities: No abnormalities noted. Pt. had full ROMx4. Strong and equal PMSx4. No edema in the lower extremities. Skin: Pt's skin was pink, warm, and dry. No diaphoresis, bleeding or bruising noted.

80 CHART Documentation TX: Pt. was assessed in residence while walking out. Pt. stated CC/HPI. Medications, Allergies, and Demographics were collected. Pt. was assisted to the litter, secured via 5 seatbelt straps, covered with a blanket and wheeled to the unit for transport. Pt. was placed into medic unit on the litter and properly secured within unit without incident. Baseline vitals obtained; all within normal parameters. Pt. transport was initiated to GEC; routine. Vitals were collected and monitored throughout transport with no changes in Pt s condition, vitals or mental status. TOC: Upon arrival at GEC, Pt. was wheeled into the ER on the cot. Pt. was registered and assigned bed. Pt. was wheeled to bed, beds placed at equal heights and Pt transferred beds via their own strength. A verbal report was given to ER RN with no further care by F/R. Medic 7xx later returned available. Narrative Written by: HIPPA Signature Obtained by Patient. TOC Signature obtained from RN receiving report.

81 CHART Documentation C (Chief Complaint) - "I cant breath'. H (History) - Dispatched to a Residential - House/Apartment/Dorm for a 58 year old Female, complaining of Breathing Problem - MPDC 6. The patient was found In the care of E7xx after a small vehicle fire outside the house.. Events prior to the incident: pt states she had been feeling ill for the last couple of days. She states she has been to georgetown, GW, holy cross, and a hospital in california to see a specialist for her problem. She reported she was having facial paralysis with trouble breathing even though non was noticed. pt was inside the house as stated by her when the fire started.. A (Assessment) - pt wasassessed on scene by E7xx. care was transfered to us and was noted that the pt was having some behavioral isssue. inside the unit, she stated she was having facial paralysis and insisted that she was going to die. She stated she has been to hospitals all over the area and nothing has resolved the issue. pt stated refused to have blood pressure taken and pulse ox of 99%. pt stated hospitals dont do anything for her, Her medical hx was given to the Rn on arrival who have a good knowledge of the pt from previous visits. - Rx (Rendered Treatment) - pt was placed in the back of the unit, strapped for safety, packeged and transported priorit 3. T (Transport) - The patient was transported No Lights or Sirens. The patient remained anxious enroute stating that she needed a place to die, and that she was having facial paralysis. ernoute to the hospital pt was being extremely unstable mentally and was yelling at the EMT. on arrival to the hospital, the pt was placed in the waiting room after the triage nurse saw her. pt started yelling stating that we brought her to the hospital forcibly when she willingly wanted to go. pt refused to sign the chart, EMT in charge and driver signed as witness. Hospital RN also signed. D (Destination) - The patient was transported to Washington Adventist Hospital The destination was determined by Closest Facility.

82 CHART Documentation AOSTF 59 yo M sitting on his couch. PE7xx was already on scene and assessing the pt. C- Patient did not specify a chief complaint. He did not state that anything was hurting or why he needed to go to the hospital. Not knowing the patients base line PE7xx and A7xx strongly encouraged the patient to get evaluated at the hospital because we did not feel the pt should be at home by himself. H- Pt has called 911 several times this week. The pt previously called 911 a few hours prior and refused transport to the hospital. While ems was on scene pt stated that he called 911 because he wanted his vitals assessed. The second time the pt called 911 the patient was initially refusing transport. The pt ordered us to leave his apartment because " going to the hospital makes everything worse". Once the patient calmed down we were able to convince him to go to the hospital. Pt did not answer our questions directly and we were unable to obtain pertinent medical history. A- Pt was alert and able to state who he was, where he was, and what day it was. We were not able to assess whether or not the pt was at his baseline because the pt wasn't able to give us a medical history. Pt is breathing normally Pt skin is warm, pink, and dry. Pt airway is patent. Pt stated that he had emphysema and he had swelling and pain in his legs. Pt denied an other pain or injury. When we attempted to obtain a sample and opqrstu pt would not answer our questions. Pt constantly repeated " its too complicated i don't have time for this" While in the ambulance pt stated that he was agitated because we went a different route to the hospital than he wanted. R- Pt was assessed and vitals were attempted. Pt told us that we couldn't take his blood sugar because he had just eaten. When asked if he was diabetic he stated that he was not. When we attempted to take his blood pressure he stated that i could not because he needed to mentally prepare before we could take his blood pressure. Although there were several attempts at getting vitals pt did not give us permission to do so. T Pt only wanted to go to WAA and stated " let me out" when we told him that holy cross hospital was a closer option. Pt was alert during transport. Pt attempted to remove his seatbelt because he was getting a cramp in his leg. The ambulance was stopped immediately and did not proceed to the hospital until the pt was calm and his seat belts were properly buckled. The pt asked me to hold his hand because it calms him down. Pt was placed in bed 14 and pt care was transferred to WAA.

83 CHART Documentation Transport Reimbursement- What Do I Need in My Report? Good demographics Patient name should be spelled correctly Obtain patient address Social Security Number Date of Birth

84 CHART Documentation MCFRS cannot bill unless the narratives show medical necessity. Basically if the narrative does not show that it would have been counter intuitive to use other transportation then medical necessity it not met. Of course there are patients we take that don't meet medical necessity guidelines, those are not billed. A quick example, 10yom spinner stuck on index finger left hand, tried to remove with soap and water not successful, moved patient to unit, transport to hospital. This would not be a billable run as written. If however the 10yom was in a great deal of pain or the finger was becoming discolored and the provider failed to note those facts in the narrative it could have been a billable run.

85 CHART Documentation- REMEMBER!! Scene MOI/ Nature of Illness Events leading up to incident Assessment Findings Treatments and patient response to treatments Any changes in patient condition Any extenuating circumstances

86 Short Forms Short forms should be completed at hospital A COPY of the short form should be left with the charge nurse A patient care report must be completed ASAP Toughbook Desktop computer The ORIGINAL copy of the short form must be sent to Debi Messett- 2 nd PSHQ

87 Documentation Refusals

88 Patient Refusal Documentation Competent, adult patients have the right to refuse treatment and/ or transport Litigation rate for EMS is increasing Liability can result from many different factors including incomplete assessment, missing major signs/ symptoms, and improper documentation

89 Patient Refusal Documentation Assessment should include: history of present illness (HPI) past medical history (PMH) medications head to toe exam mental status suspected drug or alcohol use may influence patient capacity to refuse care

90 Patient Refusal Documentation Situational Assessment Does patient understand the medical condition and risks associated if they do not get more treatment Explain high blood pressure can lead to a stroke Discuss with patient in a language the patient understands Is there a witness? Obtain a refusal and signature from patient

91 Patient Refusal Documentation The refusal documentation should clearly demonstrate: Proper documentation- document as you would a patient that you are transporting The process you went through to convince patient to seek further treatment and evaluation by being transported Witnesses to this process

92 Patient Refusal Documentation Proper documentation protects the provider(s) and agency Include care you intended to provide Do not try and talk patient out of being transported Include patient s mental status Try to include at least two sets of vitals Remind patient he/ she can call back at any time Use patient s own words- why are they refusing? Fill out refusal in front of patient and obtain signature Short forms

93 Patient Refusal Documentation Interventions- How can I convince the patient to be transported? Explain risks Involve family/ friends Medical consult Police Offer multiple times

94 Patient Refusal Documentation Billy A Browning v West Calcasieu Cameron Hospital EMS crew initially found to have followed appropriate Standards of Care Family appealed and EMS crew was found liable for: not properly educating patient as to the risks of refusing treatment and transport not performing a 12 lead on a patient c/o chest pain per protocol making changes to their report at a later time

95 Practice! Practice! Practice ImageTrend University Practice database Prior to cutover login with MIEMSS e- licensure user name and password After cutover user name: practicebls Password: practicebls1! UserVoice Ideas or suggestions? Please share!!

96 Summary Demonstrate ability to log into emeds Elite Define California Measures and how these measures relate to a patient care report Identify features in emeds Elite, including how to create a downgrade report, import vitals and procedures from the Lifepack, and utilize the auto generate narrative. Define medical necessity and produce a CHART narrative that demonstrates medical necessity Identify importance of properly documenting a patient refusal Create a patient care report utilizing emeds Elite, including a proper CHART narrative