Key Elements of EMS Documentation

Documentation is one of the least favorite parts of Emergency Medical Services (EMS) providers’ job. However, next to patient care, it is one of the most important things. Many EMS providers do not appreciate the varied and critical purposes served by their patient care documentation. Some simply see their patient care reports (PCRs) as documents casually tossed aside or ignored at the emergency department or evidence in a quality improvement review. In this article, we shared key elements of Emergency Medical Services (EMS) documentation which will help in reducing claim denials due to medical necessity. 

Key Elements of EMS Documentation

Reason for Patient’s Visit to Emergency Department

This is a basic question asked that doesn’t always make it to the medical record. It’s important to document if symptoms have progressed, changed, or if a new symptom developed before seeking emergency care. For example, a patient with abdominal pain for five days who develops persistent vomiting offers a different perspective than the abdominal pain alone. Other considerations include the inability to control pain with over-the-counter medications, the inability to tolerate fluids, and how the patients’ symptoms affect the ability to perform activities of daily living.

Patients Arriving by EMS

The process of EMS activation suggests there is a concern about a severe or life-threatening condition that requires emergency care. Documenting that the patient arrived by EMS can be used to support the medical necessity of the visit. Additionally, documenting the care rendered by EMS is helpful when that treatment results in patient improvement. For example, EMS is activated by a bystander because a patient was not breathing due to an overdose, begin resuscitation, and gave an antidote to lead to the improvement of symptoms. Upon arrival to the emergency department, the patient is now breathing with the only symptom of nausea. A payer may say that nausea does not meet the medical necessity to be in the emergency department but offering the context of pre-hospital care would refute that.

Documenting Comorbid Conditions

Documenting comorbid conditions and linking them to the presenting illness supports the medical necessity of the visit by demonstrating the severity of the illness and risk stratification. For example, the statement ‘50-year-old male with a history of diabetes, hypertension, active nicotine use presents with 1 hour of chest pain’ offers more clarity than leaving the comorbid conditions elsewhere or not documenting them at all.

Describe Your Thought Process 

Documenting a differential diagnosis, a rationale of why labs or images were or were not ordered, and your cognitive thought process that led to the final disposition is a critical component of demonstrating the medical necessity of the visit. Contemporaneously documenting responses to treatments, interventions, and reassessments can also be valuable.

Clearly Mention a Referral

Many patients are sent to the emergency department from outpatient clinics/offices, urgent care, or directly by their physician. Capturing this in the documentation notes reinforces the need for a patient to be treated at a higher level of care. 

Final Diagnosis

A final diagnosis should consider the nature of the presenting problem and what you’ve identified. If there is no clear definitive diagnosis, a presenting complaint, sign/symptom, abnormal vital sign, lab, or imaging finding may be used. Pertinent comorbidities and mechanism of injury are also options to include. For example, instead of listing syncope as a single diagnosis, a physician could add hyponatremia and long-term use of anticoagulants to the diagnosis list to provide a clearer description of the physician’s findings.

Including above mentioned key elements will make your documentation complete. Note that, complete documentation is the primary defense against payment denials. We shared an excerpt of ‘Preventing Medical Necessity Denials With Clinical Documentation’ as a reference to discuss key elements of EMS documentation. Medical Billers and Coders (MBC) is a leading medical billing company providing complete revenue cycle services. We keep on sharing the latest billing, coding, and documentation guidelines for reference purposes, you can refer to a payer or state-specific policies for more information. For any assistance in medical billing and coding services, contact us at 888-357-3226