PW&W’s Stark and Johnson provide legal insight into PCRs
FAQs on owning, amending, retaining and sharing patient care report data
This episode of EMS One-Stop With Rob Lawrence is brought to you by Lexipol, the experts in policy, training, wellness support and grants assistance for first responders and government leaders. To learn more, visit lexipol.com.
Page, Wolfberg & Wirth was asked by the National EMS Information System (NEMSIS) Technical Assistance Center (TAC) to research frequently asked questions related to data in EMS patient care reports. PW&W analyzed these questions under applicable laws and guidance, and developed general answers and best practices contained in the new publication, “Patient Care Report Data QuickGuide - FAQs on owning, amending, retaining and sharing patient care report data.”
In this week’s EMS One-Stop, available in both video and audio versions, Host Rob Lawrence speaks with the PW&W authors of the project, Ryan Stark, managing partner, and Steve Johnson, director of reimbursement consulting. They discuss the guide, why it’s needed, and the major FAQs and misconceptions about PCRs.
The guide is broken down into four key areas of FAQs:
- PCRs’ legal status
- Amending PCRs
- PCR retention
- Transferring PCR data
Top quotes from this episode
“I would much rather defend an organization who regularly goes through a quality assurance process, whereby they make the provider and hold them responsible for the accuracy and completeness of the record.” — Ryan Stark
“Others may say, we see a lot of amendments to your records. The answer is ‘yes, that’s because we care about getting it right’ – that’s the mantra of our organization.” — Ryan Stark
“One of the things behind the importance of documentation is that it doesn’t live in a vacuum. We are in a day and age where it’s going to follow the patient for their lifetime, so you may have a rehab facility that wants to consult the medical record to determine the mechanism of injury or how the injury occurred and the only person [that knows that] is the EMS practitioner.” — Ryan Stark
“Long gone are the days where we can give you a quick ticket, passing along the information to the receiving facility. Now we are marrying up records, electronic health exchanges and other mechanisms and the genesis of all this starts with the original call.” — Steve Johnson
“Everyone should sign the patient care report. Why? Because everyone was a function of providing that particular service and we get a lot of pushback and they say ‘well now I’m legally responsible for everything that happened,’ and that’s not what the law says. The law says, for what you did, you are responsible for what you did and what you didn’t do when you had a legal duty to do something or withhold doing something because it was contraindicated. All that indicates is that yes, I reviewed it and to the best of my knowledge it’s true and accurate.” — Ryan Stark
“The law will impose liability where it lands. Just because you’ve signed that particular patient care report, doesn’t mean you’re responsible for all the interventions and everything that I outlined in there, it would be whoever performed or withheld those interventions that would be responsible within the scope of practice.” — Ryan Stark
1:09 – Introductions
1:30 – PWW history
3:30 – Introducing the PCR Data QuickGuide
4:20 – The circle of life of a PCR
11:00 – NEMSIS data/research license and EMS by the numbers
13:20 – Who owns PCR data
15:50 – Signatures! And legal responsibility
17:40 – Accuracy of documentation to defend your actions
18:30 – Why does the driver have to sign?
20:00 – Amending PCRs: When and why
22:33 – Who do you tell if a record is amended?
24:30 – Can your state request you to amend your PCR?
27:30 – How long should we keep documents?
30:50 – When an agency closes down or merges
33:30 – Body-worn camera content
35:30 – Transferring paper records to digital.
37:15 – Bi-Directional data and HIE – responsibilities
40:00 – Final thoughts
- The PCR Data QuickGuide is available now, and we encourage all EMS professionals to download their copies and gain a deeper understanding of PCR data best practices. To download the guide, please follow the link:
- About NEMSIS
- About Page, Wolfberg & Wirth
About our guests
Ryan Stark is a managing partner with Page, Wolfberg & Wirth, and is the firm’s resident “HIPAA guru.” He counsels clients on labor relations, privacy, security, reimbursement and other compliance matters affecting the ambulance industry.
Ryan started in the healthcare field as a freshman in college, where he worked for a local hospital and a retail pharmacy. After college, he decided to become a lawyer, hoping to guide healthcare providers through the demanding legal issues they face. He has been with PW&W since 2007, fulfilling that ambition.
Ryan is passionate about educating EMS professionals and loves collaborating with providers and CEOs alike. He is a featured speaker in PW&W seminars and webinars, including the firm’s signature abc360 Conference, where he hosts the abc360 Game Show. Always enthusiastic, Ryan has been invited to speak at many state and regional EMS conferences, as well as national industry events. He is also an adjunct professor at Creighton University in the school’s Master of Science in Emergency Medical Services Program.
Ryan developed, and is the primary instructor for, the nation’s first and only HIPAA certification for the ambulance industry – the Certified Ambulance Privacy Officer. He also co-authored PWW’s widely used Ambulance Service Guide to HIPAA Compliance.
Ryan volunteers with local community nonprofit organizations. He was also a big brother with the Big Brothers Big Sisters program for over a decade and keeps in touch with his “little.” Ryan also enjoys hiking, running, kayaking and traveling, and spending time with son Oliver.
Steve Johnson began his career in the EMS industry in 1985, gaining valuable experience while serving as an EMT and later as director of a municipal ambulance service in Minnesota. As an ambulance service manager, Steve established his expertise in areas of operations, billing and administration.
Steve also has significant EMS educational experience. He established and served as training coordinator and lead instructor for a State Certified EMS Training Institution for EMTs and First Responders.
Steve served on both the Rules Work Group and the EMS Advisory Council to the Minnesota State Department of Health.
He joined the staff of a large, national billing and software company, where he was a frequent lecturer at national events and software user group programs. For over 7 years, Steve served as director of a national ambulance billing service and was responsible for all aspects of managing this company, including reimbursement, compliance and other activities for ambulance services throughout the nation.
Steve served as founding executive director of the National Academy of Ambulance Coding (NAAC), overseeing all activities of the Academy, including the Certified Ambulance Coder program, the nation’s only coding certification program specifically for ambulance billers and coders.
As the director of reimbursement consulting with Page, Wolfberg & Wirth, Steve is involved in all facets of the firm’s consulting practice. Steve works extensively on billing and reimbursement-related activities, performing billing audits and reviews, improving billing and collections processes, providing billing and coding training, conducting documentation training programs, and performing many other services for the firm’s clients across the United States.
Steve is also a licensed private pilot, and enjoys an active role in his church.