Documentation

[kyparamedic]

I'm heading up our QA/QI committee and am really frustrated with the way we document and the resistance I get at trying to change it. The narratives, in my opinion, are very poor, often consisting of just a few lines. These are on ICU-level transfers, often vented, on multiple drips. We are strictly interfacility and do ground, rotor, and the occasional fixed-wing. We use TripTix by Intermedix and there is heavy emphasis on documenting things in the event log and assessment tabs, which I agree with, as that makes it much easier to capture data, but I still feel that the narrative should give an overall story of the events leading up to their hospitalization and what happened on transport. It's hard to look at the event log and really get much of a sense of that, other than to know what meds were given, what procedures were done, and if the patient got "better, worse or unchanged" as a result. I have a pre-hospital background as do most of our medics, so the medic charting I feel is pretty good, whereas the nurses' is really lacking. Maybe it's just the different backgrounds? Whenever I bring up beefing up the narratives to include more detail or description of what happened on the call, I'm told things like "that's double-charting" or "the more detailed you are, the more it can hurt you in court." There really is a mindset of "less is more" and that if it's in the event log or assessment tab, or anywhere else in the chart, it doesn't need to be mentioned in the narrative. I agree that you don't need to give all the details in the narrative, like that they had a 20ga PIV in the right forearm with normal saline infusing at 100ml/hr, but if you increase that to 150ml/hr, even though it's charted in the event log, it should still be mentioned in the narrative with an explanation. Something as simple as "IV fluid infusion rate increased due to suspected dehydration." Although I think it should really go into even more detail as to why you suspect dehydration. Basically your decision-making should be explained. Just charting that it was done in the event log is not sufficient. Am I wrong here? Any data or things I can use to refute this whole notion that the more you document, the more it can hurt you? I've always been told the complete opposite, but maybe I was told wrong...

 

[CANMAN]

I'm heading up our QA/QI committee and am really frustrated with the way we document and the resistance I get at trying to change it. The narratives, in my opinion, are very poor, often consisting of just a few lines. These are on ICU-level transfers, often vented, on multiple drips. We are strictly interfacility and do ground, rotor, and the occasional fixed-wing. We use TripTix by Intermedix and there is heavy emphasis on documenting things in the event log and assessment tabs, which I agree with, as that makes it much easier to capture data, but I still feel that the narrative should give an overall story of the events leading up to their hospitalization and what happened on transport. It's hard to look at the event log and really get much of a sense of that, other than to know what meds were given, what procedures were done, and if the patient got "better, worse or unchanged" as a result. I have a pre-hospital background as do most of our medics, so the medic charting I feel is pretty good, whereas the nurses' is really lacking. Maybe it's just the different backgrounds? Whenever I bring up beefing up the narratives to include more detail or description of what happened on the call, I'm told things like "that's double-charting" or "the more detailed you are, the more it can hurt you in court." There really is a mindset of "less is more" and that if it's in the event log or assessment tab, or anywhere else in the chart, it doesn't need to be mentioned in the narrative. I agree that you don't need to give all the details in the narrative, like that they had a 20ga PIV in the right forearm with normal saline infusing at 100ml/hr, but if you increase that to 150ml/hr, even though it's charted in the event log, it should still be mentioned in the narrative with an explanation. Something as simple as "IV fluid infusion rate increased due to suspected dehydration." Although I think it should really go into even more detail as to why you suspect dehydration. Basically your decision-making should be explained. Just charting that it was done in the event log is not sufficient. Am I wrong here? Any data or things I can use to refute this whole notion that the more you document, the more it can hurt you? I've always been told the complete opposite, but maybe I was told wrong...

I am not familiar with TripTix by Intermedix but it sounds like a crappy charting system for what you're trying to accomplish/what you would like your programs documentation standards to be raised to. We use EMS Charts at my program and it provides the same ability to pull data, but page 8 is essentially your "event log" allowing you to document vitals and "add actions" such as medications and interventions in here, but also allows you to put those justification notes in with that add action such as "250 ml fluid bolus started per protocol for current hypotension below goal, patient not symptomatic at this time". That note would accompany an add action label that says "medication" for example.

In EMS Charts it has a section for "HPI" which sounds like your narrative section. Our nurses are also documentation minimalist here because we forward a copy of the sending chart to billing as well with every IFT flight we do however, this is not how I was taught to document in classes which covered proper documentation and covered billing practices for CCT and HEMS.

I basically document the HPI as: age, gender, weight, why they came to the hospital and how (POV vs. 911), symptoms, what the sending hospital found as the DX and concerns, what they gave to improve/stabilize the patient (not doses there's another section for that but something like: outside hospital CT scan shows large thalamic bleed and patient was given Keppra and started on Cardene for control of on-going HTN). Then I document WHY the patient is being transferred. "Patient is now for emergent air medical transfer to BLANK for neurosurgical services not available at the sending facility. Thats my HPI.

From the billing stuff I am aware of there are very few parts of a chart that billing companies and Medicaid actually look at for transports to get full reimbursement. The main section being the HPI to see what the DX is, and why they require transfer to another facility. We also have a page 9 which allows you to check some boxes which are also submitted for medical justification of the flight like "medicated infusions outside the scope for pre-hospital providers" "patient on non-standard ventilator settings" "patient with rapidly evolving condition or high risk for decompensation" etc. In that HPI there are some automatic words that pretty much guarantee reimbursement like "shock" for example and I think it's important to include those if justified with whats going on with the patient.

On page 8, the "event log section" we will start our documentation from the time we hit patient side and start trending our vitals and document stuff like "patient moved to cot, secured, report obtained" and interventions by flight crew.

One of the things I like about EMS Charts is the ability for management and crew level peer review / QA. Our on-coming crews QA the previous shifts chart and assign QA flags which must be answered. This has really brought our charting up to par. In my current program I attribute the crappy charting from the RN's just due to laziness, as my previous program which were extremely tough on charts and had well defined documentation standards the RN's charting was great.

As far as the legal concerns, I am not aware of how the type of documentation I have described above is "double documenting" as I am not re-writing what a sending MD has written on a transfer note, just a synopsis of why the patient is being transferred and what justifications there are for critical care..... Just my 0.02 cents. I am sure others will weight in on this factor.

 

[VFlutter]

EMSCharts here as well. My HPIs are like novels and I have never had an issue with billing. I always including thought process and rationale with medication and interventions. Some people chart very basic but as long as the required information is present and there are no issues with billing, insurance reimbursement, or clinical quality then I guess it is not really an issue. You may not like how it reads or flows but doesn't necessarily mean it's wrong.

 

[Carlos Danger]

I'm heading up our QA/QI committee and am really frustrated with the way we document and the resistance I get at trying to change it. The narratives, in my opinion, are very poor, often consisting of just a few lines. These are on ICU-level transfers, often vented, on multiple drips. We are strictly interfacility and do ground, rotor, and the occasional fixed-wing. We use TripTix by Intermedix and there is heavy emphasis on documenting things in the event log and assessment tabs, which I agree with, as that makes it much easier to capture data, but I still feel that the narrative should give an overall story of the events leading up to their hospitalization and what happened on transport. It's hard to look at the event log and really get much of a sense of that, other than to know what meds were given, what procedures were done, and if the patient got "better, worse or unchanged" as a result. I have a pre-hospital background as do most of our medics, so the medic charting I feel is pretty good, whereas the nurses' is really lacking. Maybe it's just the different backgrounds? Whenever I bring up beefing up the narratives to include more detail or description of what happened on the call, I'm told things like "that's double-charting" or "the more detailed you are, the more it can hurt you in court." There really is a mindset of "less is more" and that if it's in the event log or assessment tab, or anywhere else in the chart, it doesn't need to be mentioned in the narrative.

EMS is the only part of healthcare where "the more you write, the better" is the considered the norm. Documentation by exception is the rule, because it is easier and is legally defensible. I'm not familiar with TripTix but if objective information (times, VS, drugs, IV's, etc.) is already listed in the report, that paints 90% of the clinical picture almost every time. This is especially true if you are talking about an interfacility, where the sending physicians' notes already explain the overall situation in detail.

I agree that you don't need to give all the details in the narrative, like that they had a 20ga PIV in the right forearm with normal saline infusing at 100ml/hr, but if you increase that to 150ml/hr, even though it's charted in the event log, it should still be mentioned in the narrative with an explanation. Something as simple as "IV fluid infusion rate increased due to suspected dehydration." Although I think it should really go into even more detail as to why you suspect dehydration. Basically your decision-making should be explained.

Why do you think that? Why is it important? Who is it important to? What impact will it have on the patient? What harm would come from not explaining in detail why you suspected dehydration?

Just charting that it was done in the event log is not sufficient. Am I wrong here? Any data or things I can use to refute this whole notion that the more you document, the more it can hurt you? I've always been told the complete opposite, but maybe I was told wrong...

I think you are. I don't think it is necessarily bad to write more than you need to, but it definitely isn't necessarily good, either.

Documenting more throughly than necessary helps you less than you think, and in some cases, yes it might even hurt you. Look at it this way: If something bad happens to the patient and it can be traced to your actions, you are going to get called on the carpet no matter what or how you documented. Writing a lot isn't going to protect you. If your patient has a good outcome on the other hand, then nothing bad is going to happen to you, no matter what or how you documented.

Write what is important. Explain what you found, what your thought process was, and what you did about it. Most of that is evident from the vital signs and event log section of your report. There's no need to write an essay explaining in detail every thing you saw and thought in an attempt to thoroughly justify everything you did. If you are deviating from the standard, then explain why you though that was the right decision. That still doesn't usually take a ton of verbiage and reiterating information that exists elsewhere in the report.