Chief Complaint on a IFT run

[elly]

Hi guys I'm new here and well I had a question to ask. I am about to begin working for a company that only does IFTs. I was wondering something, say if I was dispatched to transport a patient being discharged from a hospital to a SNF or say a dialysis run. What would I put as the chief complaint on my PCR. Any help would be great.

Thanks in advance.

 

[squrt29batt12]

hello, you can put S/P Dx:______ (status post, diagnosis)

ex. S/P Dx: ESRD
for dialysis

ex. S/P Dx:CVA
for a pt being discharged that went to the hospital in the first place for a cva


etc...
and you can also just put Dx: to state the diagnosis, the s/p is more of a filler lol

 

[medicdan]

Welcome to EMTLife!

Have you had your orientation with this company yet?
Your answer will depend on how your company bills. generally, I put a medical chief complaint/condition, not the reason for transport. For a discharge I will say, "s/p CABG, PMH below", or "R arm fracture, repair". For dialysis transports, the CC is always "ESRD" or End Stage Renal Disease, "CRF" Chronic Renal Failure or "ARF" Acute Renal Failure.

 

[elly]

Wow thank you so much guys, that is a great help and I haven't had my orientation with this company yet. And I'm really happy to have found this Forum, it has so much information, its great.

 

[JPINFV]

ex. S/P Dx: ESRD
for dialysis

If you're on a dialysis transport, than there is nothing status post ESRD with that transport. A return could be "CC: ESRD, S/P dialysis" though.

In general for discharges or transfers, I use the diagnosis as the chief complaint. A "S/P" would be appropriate if you know that the patient had any major procedures in relation to the CC or if the reason for hospitalization was for a specific procedure (e.g. S/P R knee replacement) and used the S/P to denote that specific procedure.

 

[crossatwood]

Don't know about your service but when i ddo my run sheets i put transfer following treatment/admission/transport for.... works for my service.

 

[emtfarva]

It all depends.

Most of the time I put the reason they were at the hospital.
Like:

Pt C/O Pneumonia S/P treatment.
Pt C/O S/P CVA with left sided weakness.
Pt C/O COPD exacerbation.
Pt is S/P fall. Pt was evaluated at ER with negative findings and was cleared by hospital staff to return to SNF.

If it is a dialysis IFT:

Pt C/O CRF, ESRD requiring hemodialysis.
Pt C/O CRF, ESRD S/P hemodialysis treatment.

For my service we have to also state the reason they have to go by ambulance:

Pt is a fall and safety risk, cannot support themselves in a wheel chair w/o risk of falling due to AMS secondary Dementia.
Pt is on hip precautions due to recent hip surgery x3 days.
Pt cannot self-regulate O2 tx due to AMS secondary CVA with left sided weakness and AMS.

We also have to write how the Pt got to the Stretcher.

Pt was transferred to stretcher, by sheet lift, into a POC.
Pt was assisted to stretcher by x2 EMTs.

Here is an example narrative:

EMTs dispatched to EMTLife Hospital for Pt discharge to inpatient rehabilitation. Upon our arrival, found 99 Y/O male Pt semi fowler's on hospital bed. Pt was CAOx3 and was found in NAD. Pt is C/O S/P elective surgery on his right knee due to DJD. Pt is S/P surgery x2 days and cleared for inpatient rehabilitation. Pt cannot safely sit in a wheel chair due to recent knee surgery. Pt cannot place and support weight on his right leg, and would be a high fall risk. Pt was transferred to stretcher, by sheet lift, into a POC. Pt was secured and transported to Ambulance by stretcher. Pt's VS and PM Hx was noted. Pt was transported to AnyWho NH w/o changes in his condition. Pt was transported to unit and his room by stretcher. Pt was transferred into bed by sheet lift. Pt was placed into a POC, and left with all safety measures. Pt's report and care was transferred to nursing staff. End of report.

Does that help?

 

[elly]

emtfarva that helps a great deal and pretty much answered all of my questions. I really appreciate the thorough reply.

Thank you.

 

[Brandon O]

I just heard that our billing department actually wants us to say "Renal failure" instead of "ESRD," which insurance companies apparently don't like. Dunno how universal this one is.

 

[emtfarva]

emtfarva that helps a great deal and pretty much answered all of my questions. I really appreciate the thorough reply.

Thank you.

You are welcome. Welcome to the board. Good luck with work and keep us posted with any interesting events or any questions you might have.

Farva.

 

[emtfarva]

I just heard that our billing department actually wants us to say "Renal failure" instead of "ESRD," which insurance companies apparently don't like. Dunno how universal this one is.

I still use abbreviations.

 

[Aidey]

ESRD only applies to a certain number of renal failure patients. There are...5? stages of renal failure, with ESRD being the last one (end stage...). So it may be a technicality for your biller.

I usually ask the pt if anything is bothering them. If nothing is, then "CC: No complaint". A person can't complain of "post treatment" or "discharge".

Same thing for a unconscious patient. They don't have a complaint, they can't talk. They have a condition, but they aren't complaining of anything.

 

[Akulahawk]

Using the term "Renal Failure" vs ESRD is that ESRD is much more specific a condition whereas the former encompasses the entire range of Renal Failure conditions. It's much easier for the billers to use the former than the latter... because otherwise, if the patient is not in ESRD... and is being transported with a complaint of ESRD, payment may be denied.

Renal Failure, S/P Dialysis is much easier to bill for than, say, ESRD S/P Dialysis.

 

[Brandon O]

My understanding was that you're only getting dialysis if you're in the end stages. Is that wrong?

 

[Aidey]

Some people are acute, and others are on a 'trial run' so not always.

 

[emtfarva]

ESRD only applies to a certain number of renal failure patients. There are...5? stages of renal failure, with ESRD being the last one (end stage...). So it may be a technicality for your biller.

I usually ask the pt if anything is bothering them. If nothing is, then "CC: No complaint". A person can't complain of "post treatment" or "discharge".

Same thing for a unconscious patient. They don't have a complaint, they can't talk. They have a condition, but they aren't complaining of anything.

A person who is in the hospital and needs an ambulance to be discharged home or a SNF, to bill most insurances you must include why they were in the hospital. Along with the reason an ambulance was needed (how being transported by anyother means would endanger their lives). Yes, I will give that during the transport, they maybe stable and may not have a complaint, but you still need to document why they were at the hospital. Our new EPCRs gives us a space to do so. But I will always document why they were at the hospital in the first place.

 

[daedalus]

For transports that are discharges, dialysis, or doctor visits, for billing it is generally necessary to place the chief incapacitating condition that is creating the need for the patient to go by gurney as opposed to a wheelchair van or private vehicle.

For real IFTs like stat transports to higher level or care, you can place the presenting complaint (like chest pain on arrival at sending facility ED) or you may place the diagnosis if one has been made (STEMI).

 

[imurphy]

I just put on whatever is put on out Mednec, which is hard enough to find a reason for. Most of the time I ask a nurse the reason the patient is going by ambulance and can't take another vehicle, they generally tell me they dont know. When they ask me what they should put there, I generally tell them that they can put whatever they think is right as in the end if they just make something up, it's their licence, not mine!

 

[medicdan]

For mednec, I always put "high risk of fall", because when they are on our stretcher, they are at a high risk of fall. I often put "unable to ambulate without assistance" if true, "patient requires non-self administered oxygen" if true, "patient requires two operators for sheet carry or stair chair", "patient requires isolation precautions due to MRSA/VRE/c.diff" if true, and the list goes on. The reality is that we are putting ourselves (and the nurses who sign) at huge risk if audited by medicare, but I am always careful to rationalize my decisions.

 

[Brandon O]

If it's not obvious, I usually go to some effort to find the true medical necessity. Sure, it's sometimes as banal as "the doctor wanted to limit his liability," but in general this goes to the same reason I'm reading through the patient's chart -- I need to have some understanding of this dude's condition if I'm going to be able to intelligently provide care. If they look like Usain Bolt at his peak, with no history that seems pertinent, then I want to know why they're taking an ambulance, because maybe either someone made a mistake or maybe he has Idiopathic Sudden Head Implosion Disorder and this is something I need to know ahead of time.

That said, risk of fall, can't walk, psych patient, isolation precautions, or monitoring for xyz medical conditions will cover most everyone. Some poor RN is signing whatever I put down, usually without looking at it, so it seems like professional courtesy not to expose them to blatant falsehood.