Common examples of incomplete EMS documentation include missing signatures and missing mileage, both vital pieces of EMS documentation required in order to bill for services.
Examples of inconsistent EMS documentation include things like a patient care report narrative that states a patient has an altered level of consciousness but Glasgow Coma Score is missing/contradictory, or the patient care record narrative states that the patient is complaining of pain but there is no numeric pain scale. This JEMS article on documentation and patient care is a great post to share with your EMS staff on a full spectrum of common mistakes.
Avoiding Errors in EMS Documentation
Those responsible for documenting a dispatch record or patient care report need to ask two important questions before finalizing their EMS documentation:
- Is my documentation complete?
- Is my documentation consistent?
These two questions are key to coding an ambulance transport claim correctly and getting reimbursed appropriately. It is also important to have QA review processes in place on EMS documentation to be sure that all mistakes and omissions are recognized and corrected prior to the EMS documentation being forwarded to EMS billing. As mistakes and omissions are found, the EMS documentation should be sent back to the originator to fix, since they are responsible for that specific patient record.
EMS Software Solutions Should Help Not Hinder Accurate EMS Documentation
A good EMS software solution can help with EMS documentation completeness and consistency. This starts with picking a solution that offers strong integration between dispatch, ePCR, and billing. An integrated solution that keeps dispatchers, crews, QA staff, and billers all on the same page and working together to ensure accuracy.
Another must-have in a quality EMS software solution is automated validation checks that prevent missing and inaccurate records. Lastly, the EMS software solution should have a quality assurance workflow built into the program to ensure your agency isn’t missing any training opportunities.
Steps to Ensuring Quality EMS Documentation
It would be great if we could just tell dispatchers and crews to make sure they are consistent and complete with their EMS documentation processes, and that’s all it took. However, we must recognize that these folks have a lot on their plate… namely saving lives. So how can we reinforce the value of quality EMS documentation in relation to the important work they do?
- Initial EMS documentation training that not only explains what they need to do, but why.
- Invest in an integrated software solution with validation and Q.A. automation that helps make EMS documentation easier.
- Routine inspection/Q.A. that includes reinforcing positive results and offers ongoing training for negative results.
- Measure and share results. Let your team know if X dollars are lost due to poor EMS documentation and what kind of impact that has on operations and patient outcomes.
- Comply or goodbye. If you have staff that you have tried everything with but the quality of their EMS documentation continues to cost you in both compliance and revenue, get them on a formal review plan and if things don’t improve it is time to part ways.
AIM Can Help With EMS Documentation Challenges
From EMS Dispatch, ePCR, and EMS Billing Software, AIM offers a full line of online EMS Software that can handle all of your EMS documentation. Or, if you want a team of EMS billing processional to handle your agency’s billing for you, explore our EMS Billing Services. To learn more about AIM EMS Software and EMS Billing Services, call 1-800-726-4690, fill out our online information request form, or read more about ambulance billing best practices.