# IFT Narrative



## Aerin-Sol (Dec 5, 2010)

I work BLS at an IFT agency. Most people at my agency use simple narratives, ie "Dispatched Code 1 to [hospital]. Pt sheet pulled to strecher. Vitals monitored en route. Sheet pulled to bed. Care given to nursing staff at [nursing home]. EOR." 

I've been trying to do a bit better and use the CHART method, and I'm wondering how other people do it. I've been doing:

Cc - [what the CC is on the face sheet or other hospital papers]
Hx - See page 1 (where we document med history, allergies, and meds)
A - Patient found lying supine in hospital bed, AOX3. Pt denies any pain. Pt unable to ambulate due to hip replacement. Pt's vitals are good. (vitals are documented elsewhere on the page). 
Rx - Pt placed in position of comfort. Denies SOA. Vitals monitored during Tx.
Tx - Dispatched Code 1 to [hospital]. Pt xferred to stretcher via sheet pull, with nursing staff assistance due to hip injury. Tx Code 1 to [nursing home]. Pt xferred to bed with nursing assistance. No problems.

Is this enough for a routine IFT call? Should I be documenting something else?


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## MMiz (Dec 5, 2010)

When I worked IFT calls we were required to CHART all calls, as you mentioned above.

A few things I was required to add (a lot of it was abbreviated).
1.  Tx - Patient secured to cot with straps x3.  Handrails raised.
2.  Tx - Full report given to NH staff.
3.  Tx - "Pt. monitored with no significant change in condition."
4.  A - I had to be more specific than "denies any pain."  I said "Pt denied head pain, - N/V, - chest pain, - extremity pain."

Once you do it a few times it only takes a minute or two.


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## Aidey (Dec 5, 2010)

Denies SOA is an assessment finding, not a treatment.


Edit: Also, history isn't just for past history, it is also for history of the acute event that landed the pt in a position where they need transport.


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## Aerin-Sol (Dec 5, 2010)

MMiz said:


> When I worked IFT calls we were required to CHART all calls, as you mentioned above.
> 
> A few things I was required to add (a lot of it was abbreviated).
> 1.  Tx - Patient secured to cot with straps x3.  Handrails raised.
> ...



Thanks. I'll add those from now on.


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## Aidey (Dec 5, 2010)

Sample narrative for the same type of patient

Presenting problem: Discharge from hospital.
CC: Hip pain

Hx: The patient is a 80 year old female who is being transferred from ABC hospital to XYZ nursing home, where she currently lives. The pt was evaluated in the ED for a fever and is being discharged back to the facility /c additional treatment orders. The pt is being transferred via ambulance because she has a recent Fx of the R hip and needs to lie flat. 

The pt was contacted lying in bed, asleep. Staff report that after APAP and IV antibiotics the pts fever was reduced to 99.0 and she has been sleeping since. Pts condition remained unchanged during transport. 

Assessment:
General: Pt contacted lying in bed. Pt is atraumatic. Pt is stable.
Neuro: GCS 15
HEENT: Airway open. Pupils PERLA. No cyanosis around the mouth.
Neck: Trachea midline.
Chest: Equal and bilateral chest rise and fall /c inspiration and expiration. (-) Increased work in breathing.
Abd: Foley cath in place. 
Extremities: CSM intact x4. Pts R leg in brace.

R: See treatment and response (Treatment and response is a flow sheet in an other part of the chart)

T: Pt slid from bed to gurney /c draw sheet. Seat belts and shoulder straps applied. Gurney moved to ambulance. Pt transported code 1 /s incident to XYZ nursing home and transferred to room 101. Care was turned over to the nursing staff there. Pts discharge papers, including 3 prescriptions were left /c the RN.


It makes it a lot easier for billing if you write in your narrative why the patient is being transferred via ambulance. It gives you a chance to expand on whatever the PCS said. A problem we run into is that the PCS will say that the pt can't travel by wheelchair, but the patient is wheelchair bound in their normal lives. We have to explain little things like that. A number of times the problem has been that the pt uses a specialized wheelchair, which was not taken to the hospital with them, and they can't sit in a normal wheelchair to go home in a WC van.


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## Amber2313 (Dec 5, 2010)

Aidey said:


> It makes it a lot easier for billing if you write in your narrative why the patient is being transferred via ambulance. It gives you a chance to expand on whatever the PCS said. A problem we run into is that the PCS will say that the pt can't travel by wheelchair, but the patient is wheelchair bound in their normal lives. We have to explain little things like that. A number of times the problem has been that the pt uses a specialized wheelchair, which was not taken to the hospital with them, and they can't sit in a normal wheelchair to go home in a WC van.



Our go-to phrase for that, WC and otherwise, is
"Any other means of transportation is contraindicated due to..."


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## Aerin-Sol (Dec 5, 2010)

What do you do when you have patients who don't really need an ambulance?


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## Amber2313 (Dec 5, 2010)

Aerin-Sol said:


> What do you do when you have patients who don't really need an ambulance?



Example? Like a walk-on?


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## Aidey (Dec 5, 2010)

Well, if you don't want to commit fraud you explain. 

Recent example. Per staff the patient is being transferred via ambulance because she states that she is too dizzy to stand. Upon arrival at the Pts SNF we offered to transfer the pt directly to her bed or a wheelchair. The pt instead requested that we lower the gurney in the hall, and then she proceeded to walk unassisted 10-12 feet into her room without any obvious difficulty. 

Let billing sort it out from there.


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## MMiz (Dec 5, 2010)

Aerin-Sol said:


> What do you do when you have patients who don't really need an ambulance?


Most likely a physician or his/her delegate will fill out a form of some sort stating the person's medical need for ambulance transport.  When I worked in EMS it was our responsibility to make sure we had that prior to transporting from a hospital or nursing home.

In cases where I was called to a home, I would do exactly as Aidey described.


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## Shishkabob (Dec 5, 2010)

Dispatched for a 47yo W/F with hx of cervical cancer.  On arrival, found patient in bed, ABCs cleared, pt in no obvious distress.  Pt had IV of NS running TKO, IV in right AC.  Pt moved to cot under own poer with help, strapped x3, rails raised x2.  Pt moved to MICU, vitals done as noted, transport initiated.  IV site monitored during transport. At destination, pt moved to bed, rails raised x2, report given to nurse.



Usually wrote a bit more but I'm doing this from my phone so oh well


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## JPINFV (Dec 5, 2010)

MMiz said:


> Most likely a physician or his/her delegate will fill out a form of some sort stating the person's medical need for ambulance transport.  When I worked in EMS it was our responsibility to make sure we had that prior to transporting from a hospital or nursing home.
> 
> In cases where I was called to a home, I would do exactly as Aidey described.



My understanding is that a "Physician Certificate of Necessity" (which can be signed by basically any healthcare provider with adequate knowledge, so RNs, NPs, and PAs can sign, not just physicians despite the name) is needed for all non-emergent medicare transports. However recurring trips, such as dialysis, are good for a couple months (3 if I recall correctly, but don't quote me), so you don't need to get 6 forms filled out for Jane, the 3 times a week dialysis patient.


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## Amber2313 (Dec 5, 2010)

JPINFV said:


> My understanding is that a "Physician Certificate of Necessity" (which can be signed by basically any healthcare provider with adequate knowledge, so RNs, NPs, and PAs can sign, not just physicians despite the name) is needed for all non-emergent medicare transports. However recurring trips, such as dialysis, are good for a couple months (3 if I recall correctly, but don't quote me), so you don't need to get 6 forms filled out for Jane, the 3 times a week dialysis patient.



I think we do them annually. I'm almost positive, actually.


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## MMiz (Dec 5, 2010)

JPINFV said:


> My understanding is that a "Physician Certificate of Necessity" (which can be signed by basically any healthcare provider with adequate knowledge, so RNs, NPs, and PAs can sign, not just physicians despite the name) is needed for all non-emergent medicare transports. However recurring trips, such as dialysis, are good for a couple months (3 if I recall correctly, but don't quote me), so you don't need to get 6 forms filled out for Jane, the 3 times a week dialysis patient.


We had an inservice on the forms that said that a Physician or PA needed to sign, and possibly an RN with additional training.

For our dialysis and regulars we were required in 2004 to get new forms signed every three months, whereas in the past it was a year.


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## Amycus (Dec 5, 2010)

Hello. I don't follow a specific method, but if I did, it's very close to CHART.

All my narratives for IFT basically read like the following- ASSUMING ALL OF IT IS TRUE (I won't say "uneventful transport" for example, if something happened).

<unit> dispatched for transfer of PT from <pickup> to <dropoff>. Upon arrival, staff reports PT was admitted for <insert reason here>. PT has been treated and is being returned for definitive care/rehab/home, etc. PT found in their hospital room <insert how I found the PT>. PT is a <insert demographics, age, sex, etc>, presenting as <How AO are they?>, <pink, warm, dry?>, <chief complaints if any still>? General comment about demeanor of PT (plesant, conversational, agitated, aggressive, frustrated, etc.). PT's personal possessions and documentation gathered. PT transferred to stretcher using <insert method here>. PT made comfortable in a <insert position> and secured x5 with both rails up. PT brought out to <unit number> for transport. During transport, PT's condition and vitals monitored. Transfer was uneventful, with no voiced improvements or degradation in PT condition. PT <insert comment about PT's general demeanor on the ride, i.e. was asleep majority of the trip, conversational, appeared confused, etc. Upon arrival, PT brought to <wherever>, made comfortable, and personal possessions left with staff. PT care transferred to staff at <facility> with no incidents or delays. 

Any other relevant information added obviously- if they were on O2, required something specific during transport, etc.

I've used that same narrative, tailored to each PT for 7 months and our QA/QI department has had no issues with my documentation. I guess though, in retrospective, my documentation is pretty similar to CHART, just done in a different manner...


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## TransportJockey (Dec 5, 2010)

Aerin-Sol said:


> I work BLS at an IFT agency. Most people at my agency use simple narratives, ie "Dispatched Code 1 to [hospital]. Pt sheet pulled to strecher. Vitals monitored en route. Sheet pulled to bed. Care given to nursing staff at [nursing home]. EOR."
> 
> I've been trying to do a bit better and use the CHART method, and I'm wondering how other people do it. I've been doing:
> 
> ...



When I worked for a strictly IFT service, the report you describe at teh beginning would have gotten the person who wrote it a very strong warning the first time they did it, and a suspension the 2nd time, and fired the third. 
I followed CHART when I worked IFT, and still do now that I'm doing 911/transfers.


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## Aidey (Dec 5, 2010)

JPINFV said:


> My understanding is that a "Physician Certificate of Necessity" (which can be signed by basically any healthcare provider with adequate knowledge, so RNs, NPs, and PAs can sign, not just physicians despite the name) is needed for all non-emergent medicare transports. However recurring trips, such as dialysis, are good for a couple months (3 if I recall correctly, but don't quote me), so you don't need to get 6 forms filled out for Jane, the 3 times a week dialysis patient.



RN, MD/DO, PA, NP, "CNS" and "discharge planner" can sign and fill them out. Only a MD/DO can sign a recurring one. They are good for either 3 months or 90 days, I can't remember the exact wording. 

In response to MMiz - 
A VERY frequent problem we have is nothing being written under the "explain why other means of transport is contraindicated" section or the "describe the patient's condition" section. Completley missing the fact the form says "mandatory" under both sections, people still get pissy with us when we try and get the form filled out properly. There is also a problem with incomplete explinations. Such as "can't walk". Ok, well why can't they walk, and that does nothing to explain why they can't go in a WC van. Since we can't legally fill them out, I always explain further in my narrative. It reduces how often my charts get kicked back as needing additional info before a payout can be made.


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## Aerin-Sol (Dec 6, 2010)

Aidey said:


> In response to MMiz -
> A VERY frequent problem we have is nothing being written under the "explain why other means of transport is contraindicated" section or the "describe the patient's condition" section. Completley missing the fact the form says "mandatory" under both sections, people still get pissy with us when we try and get the form filled out properly. There is also a problem with incomplete explinations. Such as "can't walk". Ok, well why can't they walk, and that does nothing to explain why they can't go in a WC van. Since we can't legally fill them out, I always explain further in my narrative. It reduces how often my charts get kicked back as needing additional info before a payout can be made.



Exactly. They frequently won't be filled out, and when we ask the RN to fill them out, they will put in an incorrect reason code, or they will be pre-filled out with an incorrect reason. I've even had RNs look at the sheet, go "Hmm it doesn't really fit any of these, so I'll just check.... this one" and end up with something silly like more than 3 steps required to enter an assisted living home with ramps and elevators.


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## Aidey (Dec 6, 2010)

And in those cases I just explain it in my narrative.  Staff advise the pt is being transferred via ambulance because she can not ambulate up steps. The pt reports that she normally ambulates with a walker. It was noted at the pts residence that there were ramps and elevators available.


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## Hockey (Dec 6, 2010)

Dispatched to above location P'X'. ATF 'X' M/F (insert where I found patient).  Pt complains of (or why patient is going to X location).  (If 911) Pt/Family/Staff states patient (Insert story).  

Pt moved to cot (or preferibly walked with assistance  via whatever way), rails locked upright, secured with all available belts, and moved to ambulance without incident.

V/S and interventions as noted (Why should I need to repeat whats already in the PCR?) (Add anything that was abnormal that really needs to be emphasized)

Pt transported while being monitored for changes without incident.

Pt moved (to whatever, via whatever method) without incident.  

Pt care turned over to 'X person'

Sometimes I'll add patient cannot stand, pivot or ambulate due to X condition.

No reason to be lengthy


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## CAOX3 (Dec 6, 2010)

Not to hijack here and forgive I'm not that familiar with medical med necc. forms but if the emt or paramedic doesn't have the ability to veto the transport because the patient doesn't fit the criteria for transport by ambulance.  Your basically operating on their word that the patient fits the criteria.  Wouldn't it cut down on fraud and unnecessary transports if the facility was now held responsible for the outstanding balance? They would not be so quick to sign their name if they the facility were being held financially responsible.


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## JPINFV (Dec 6, 2010)

CAOX3 said:


> Not to hijack here and forgive I'm not that familiar with medical med necc. forms but if the emt or paramedic doesn't have the ability to veto the transport because the patient doesn't fit the criteria for transport by ambulance.  Your basically operating on their word that the patient fits the criteria.  Wouldn't it cut down on fraud and unnecessary transports if the facility was now held responsible for the outstanding balance? They would not be so quick to sign their name if they the facility were being held financially responsible.



While the individual EMTs and paramedics might not have the ability to refuse a transport, dispatch does. Unlike 911, there is no duty to respond and transport non-emergent patients and a quick call to dispatch could end with being unassigned. 

However, in most cases dispatch will say to transport anyways. Most of the time a company has a contract with the sending facility and too many transport refusals could end up with a lost contract. How many patients are you willing to lose because one patient wasn't being reimbursed?


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