weird abbreviations in my company

[gastro18]

THE DUMBING OF NEW RECRUITS AND SPONTANEOUS INVENTION OF ABBREVIATIONS

ok. this is the situation. i've been working 2 years in this company and i've had no problem at all with my PCRs. Recently, I noticed that the new recruits have been doing things that I haven't been doing. The funny thing is, they get in trouble if they don't do these NEW things; and I don't. Because I stick to what I think is right, and what makes sense.

FIRST: they're making the newbies write "Pt needs ambulance because of...." I mean what's up with this? I believe once you write your chief complaint and corresponding assessments, history, and what went down with the call, that's it. It sounds like my company is passing the buck of ambulance determination to our new recruits. We handle a lot of majority IFTs. And I'll tell you, we also recruited some questionable marketers who know insiders in some facilities. So there are times we are responding to 'ER to home' calls and the patient is outside the ER, smoking cigarettes and leisurely ambulating w/o assistance. Doesn't sound kosher, right? For me, I just right honestly, what I saw, heard, smelled, etc. I don't take it upon myself to make a determination if it's an unbillable call or not. I just get paid by the hour and work within my scope of practice. that's it. I question the new recruits (most of them fresh out of EMT school) and they say our management even provides them a template on how to write their PCRs. And allegedly, there's a portion there that says, "Pt needs an ambulance because________". Man, I can imagine a Medicare suing for fraud for a questionable call. And what's gonna happen? our bosses are gonna just shrug their shoulders and testify, "well, our EMT explicitly stated that the pt needs an ambulance. We weren't on the field, he was". So these poor newbies with dreams of rescuing people and making a difference in the community, etc, might just get hung out to dry, don't you think? Totally uncool.


SECOND: In the vital sign box section at the bottom of our PCR forms, I see our new recruits writing "S/R" right after the heart rates. I asked them what it means and they say "sinus rhythm". I was like, "What!!!? we don't have EKGs! we are BLS!" Just because a pulse is deemed regular, doesn't mean it is a normal sinus rhythm. What if it's a brady, tachy, flutter, Junctional, or a 3rd degree Hb? The point is, a BLS rig doesn't have an EKG! According to the new guy, that's what our FTOs have been telling them to do during orientation. I mean, for the past two years, I just write the whole number without any fancy letters such as S/R, and I never got in any trouble. There were times, I got an irregular pulse, and I just wrote next to the HR number "Irregular". I would also write in my assessments, HR was irregular, or weak, or thready, etc. Why? Because I am BLS! I don't do EKGs! I can only auscultate and palpate. Plus S/R should be SR anyway, referring to a HR that is normal sinus rhythm -- if you have an EKG. It makes me think: if this is a new policy, then why for godsakes is my company not informing me. Makes me think there's a conspiracy to fool the newbies and not inform the veterans because the veterans would definitely either laugh, scratch their heads, or dismiss it as another shenanigan. Supposing they meant "strong, and regular" for S/R, still it is not an approved abbreviation. An EMT should just write the words "strong and regular" next to the heart rate (if there's still space left).

and FINALLY, also in the vital signs section, I see the new guys being instructed to write NTV after the respirations. (example -- 16 NTV). I mean, C'MON! the last time i heard NTV is when they're referring to NASA TV! I was just aghast, i asked the new guy, "hey what does NTV stand for?". The recruit goes, "Oh our FTO says we should write this for "normal tidal volume" . I was like "WTF!". First of all, we have a check box for the type of respirations our patient has. You can select, Normal, Apneic, Labored, etc. So who the hell is coming up with these abbreviations? I found out it's the FTO with a little more than a year's experience on the field, and a biology major. I have nothing against biology majors, but that doesn't give you the right to be inventing abbreviations. Why? Because it looks cool and makes our EMTs look smart? NO! It's totally the opposite.

So guys, correct me if I'm wrong and I'll humbly accept your verdict. But right now, I am just bewildered and don't even know what to think.

Thanks for listening
gastro18

 

[JPINFV]

[documenting necessity] So these poor newbies with dreams of rescuing people and making a difference in the community, etc, might just get hung out to dry, don't you think? Totally uncool.

To the first part, the simple solution is to not lie. Yes, if the documentation is done correctly, there isn't a real need for a "Ambulance transport necessitated by ___" section, however there are plenty of people in EMS that suck at documentation. If you don't lie, you can't get hit for fraud. It's really as simple as that.

As far as the totally uncool part, welcome to EMS. It's not as exciting as the TV shows or war stories told in class make it out to be.

[discussion of S/R]
What if it's a brady, tachy, flutter, Junctional, or a 3rd degree Hb?

Devils advocate, a bradycardia and tachycardia can both be a sinus rhythm and those other rhythms wouldn't present as regular. However, I do agree that "strong and regular" or "regular rate and rhythm" would be a better choice to document at the EMT-B level

[making up acronyms]

First off, I see nothing wrong with documenting normal tidal volume. However it should be written out unless an appropriate abbreviation is used. For example, in my current program, NCAT (normocephalic atraumatic) or WDWN (well developed, well nourished) are appropriate accronyms. However, if I was ever to work on an ambulance again, there's no way that I would use those acronyms because no one would understand them. Similarly, one of the most annoying acronyms I've seen used at my old company was "DS" for "draw sheet." Of course "DS" was also the official system wide acronym for a "dextrose stick." Hmm...

 

[Veneficus]

copy of private response for all.

Private companies have been doing this for years all around the country. The goal is to use the magic words that instantly qualifies for payment, instead of a 90 day review.

Hospitals all around the country have electronic PCRs starting in triage that only allow you to select magic words from drag and drop boxes to increase speed of payment.

It sounds like your company is trying to do this on the cheap.

Standard medical abbreviations are approved on an agency or regional basis. A good example is: D-Stick (dextrose) for a blood glucose reading. Some other places use CBG for "capilary blood glucose." If your medical director approved the abbreviations, then they are a go.

You can auscultate heart rythms. In fact that is how it was done before the portable EKGs were invented in the 60s. The auscultated diagnosis of SVT actually dates to the 1600s.

I think it is fraud to document findings you did not actually observe.

 

[EMSLaw]

Were three threads on the same issue really necessary? Anyway...

I agree with you to a point - you can't tell if a heart rhythm is sinus simply by palpation (ascultation of heart sounds being outside an EMT-B's scope). I would document the pulse by rate, rhythm (regular/irregular) and quality (80 and regular, 60 irregular and thready, Absent, etc.). Same with the respirations. 15 and regular, as opposed to 40 and shallow or irregular, or whatever. If I thought the breathing was biot's or Cheyene-Stokes or Kussmaul, I would put that in my narrative, not that it would be definitive anyway.

As to why the patient needs an amublance... I think that invites trouble. The patient needed an ambulance because they called one. You can't exactly write (if your company wants to get paid) "Patient was ambulatory and appeared to be in no acute distress, but required an ambulance because, 'I don't have a car and need to get to the liquor store near the hospital.'" Or whatever other reasons, beyond a medical emergency, people call ambulances.

 

[JPINFV]

As to why the patient needs an amublance... I think that invites trouble. The patient needed an ambulance because they called one. You can't exactly write (if your company wants to get paid) "Patient was ambulatory and appeared to be in no acute distress, but required an ambulance because, 'I don't have a car and need to get to the liquor store near the hospital.'" Or whatever other reasons, beyond a medical emergency, people call ambulances.

I'd argue that "because the patient called one" isn't an appropriate reason outside of emergency calls. There is no right (implied, moral, or otherwise) to non-emergent ambulance transport and there is nothing wrong with a company denying ambulance transport in non-emergent calls if reimbursement (either private pay or insurance) is questionable. However, decisions to transport based on reimbursement situations needs to enforced at the dispatch or supervisor level and not by individual providers, even if that means that in certain situations crews request a supervisor prior to transport.

 

[EMSLaw]

I'd argue that "because the patient called one" isn't an appropriate reason outside of emergency calls. There is no right (implied, moral, or otherwise) to non-emergent ambulance transport and there is nothing wrong with a company denying ambulance transport in non-emergent calls if reimbursement (either private pay or insurance) is questionable. However, decisions to transport based on reimbursement situations needs to enforced at the dispatch or supervisor level and not by individual providers, even if that means that in certain situations crews request a supervisor prior to transport.

Define an "emergency" call? I only have 9-1-1 experience, so all my calls are, at least in theory, supposed to be "emergency". I certainly don't have the authority or ability to deny a patient transport to the hospital. So, in essence, the reason for the transport is that they called for us.

 

[Veneficus]

there is nothing wrong with a company denying ambulance transport in non-emergent calls if reimbursement (either private pay or insurance) is questionable. However, decisions to transport based on reimbursement situations needs to enforced at the dispatch or supervisor level and not by individual providers, even if that means that in certain situations crews request a supervisor prior to transport.

I agree with what you said, but would just like to add:

Sometimes a transport company has a contract with a facility stating all patients must be transported. (I have seen it) when the patient or medicare/medicade can't py the company eats it, but does have to transport or risk being considered in breach.

 

[JPINFV]

Define an "emergency" call? I only have 9-1-1 experience, so all my calls are, at least in theory, supposed to be "emergency". I certainly don't have the authority or ability to deny a patient transport to the hospital. So, in essence, the reason for the transport is that they called for us.

Emergency call= going to the emergency room.

Non-emergent transports = going to someplace other than the emergency room (exception being emergency inter-facility transports). These transports are not normally (and not supposed to be) arraigned through the 911 system.

I agree with what you said, but would just like to add:

Sometimes a transport company has a contract with a facility stating all patients must be transported. (I have seen it) when the patient or medicare/medicade can't py the company eats it, but does have to transport or risk being considered in breach.

...which is one of the reasons why I suggested that a supervisor or dispatch is consulted. It's much easier to advise a few people in contract implications than all field providers. Similarly, just because it isn't in the contract doesn't mean it might be worth eating a transport or two in order to keep a contract.

 

[gastro18]

Devils advocate, a bradycardia and tachycardia can both be a sinus rhythm and those other rhythms wouldn't present as regular. However, I do agree that "strong and regular" or "regular rate and rhythm" would be a better choice to document at the EMT-B level

Thanks for the reply!

these guys were actually referring to their S/R abbreviations as "NORMAL sinus rhythm". Meaning, NOT an arrhythmia. (I'm sorry if i didn't put the term Normal in there)

a tachy and brady, as we both know, are sinus rhythms. There are P-waves corresponding QRS complexes. but definitely not normal sinus rhythms. they're arrhythmias/dysrhythmias

strong and regular or "regular rate and rhythm" are definitely at the EMT-B level because most EMT-Bs don't do rhythm interpretations for the simple fact that most BLS rigs don't have onboard monitoring, or it's not part of the scope of practice.

 

[gastro18]

Emergency call= going to the emergency room.

Non-emergent transports = going to someplace other than the emergency room (exception being emergency inter-facility transports). These transports are not normally (and not supposed to be) arraigned through the 911 system.



...which is one of the reasons why I suggested that a supervisor or dispatch is consulted. It's much easier to advise a few people in contract implications than all field providers. Similarly, just because it isn't in the contract doesn't mean it might be worth eating a transport or two in order to keep a contract.

Thanks for the reply.

I know what you're saying about companies with contracts. We do have such arrangements with some facilities. I dont really have a problem with that. I go to where dispatch wants me to go. But for the company to impose on EMTs to explicitly state why the patient needs ambulance is somehow "inviting trouble". of course, not all patients are billable under medicare, medical,etc. that's why companies just consider those runs as hit-or-miss runs, or 'marketing expense' to not piss-off the client facility.

Some of these companies make EMTs use these "magic words" (the patient needs an ambulance because ____...) to hustle for a payout, at the expense of the EMT who then needs to explain to a jury why he declared a medical necessity on such a questionable patient.

I say, just write the chief complaint, write the assessments and let billing and paying party decide if that call gets paid or not. Of course, assuming that documentation is accurate and makes sense.

 

[JPINFV]

...
But for the company to impose on EMTs to explicitly state why the patient needs ambulance is somehow "inviting trouble". of course, not all patients are billable under medicare, medical,etc. that's why companies just consider those runs as hit-or-miss runs, or 'marketing expense' to not piss-off the client facility.

Some of these companies make EMTs use these "magic words" (the patient needs an ambulance because ____...) to hustle for a payout, at the expense of the EMT who then needs to explain to a jury why he declared a medical necessity on such a questionable patient.

I say, just write the chief complaint, write the assessments and let billing and paying party decide if that call gets paid or not. Of course, assuming that documentation is accurate and makes sense.

Again, the simple solution is to not lie. I see nothing wrong with documenting a reason, such as, "Patient transferred to gurney via draw sheet due to bilateral BKA" (however, be careful with the term "bed confined" because there is a very specific medicare definition of this) or other exam findings. Any statements should be backed up in the PCR based off of physical exam findings or medical history anyways. Similarly, the physical declaration of medical necessity (which all non-emergent patients should have, however ones for regularly scheduled continuous transports (i.e. wound care, dialysis, etc) are good being on file for 30 days, if I recall correctly) should match up with the PCR anyways. If an exam is done and recorded in good faith, then there should be very little liability at the hands of the EMT. However, if the company is directing, and the provider is willing to follow, orders to falsify records, then there's enough moral issues on both sides.

Personally, I find it reasonable to request and require a reason to be documented if such conditions exists. If the employer is requesting that providers actively lie on their PCRs, then it's time to find another employer before the fecal matter hit's the fan.

 

[Aidey]

I replied to the other thread, but I will repeat myself here.

When we do transfers we write "Patient is being transferred by ambulance because of..." and then write in the reason right off the Medicare PCS. Per my supervisor the reason is supposed to be in the narrative somewhere, and not having it increases the chances it will be kicked back, even if it is a valid billable transfer.

So a transfer narrative may start out like this.

"The pt is a 85 year old male who is being transferred from St. Mary's Hospital to St. Anne's Nursing Home. The pt was evaluated and treated at St. Mary's for a UTI and is being discharged back to his SNF. He is being transferred by ambulance due to a recent hip fracture."

 

[MSDeltaFlt]

THE DUMBING OF NEW RECRUITS AND SPONTANEOUS INVENTION OF ABBREVIATIONS

ok. this is the situation. i've been working 2 years in this company and i've had no problem at all with my PCRs. Recently, I noticed that the new recruits have been doing things that I haven't been doing. The funny thing is, they get in trouble if they don't do these NEW things; and I don't. Because I stick to what I think is right, and what makes sense.

FIRST: they're making the newbies write "Pt needs ambulance because of...." I mean what's up with this? I believe once you write your chief complaint and corresponding assessments, history, and what went down with the call, that's it. It sounds like my company is passing the buck of ambulance determination to our new recruits. We handle a lot of majority IFTs. And I'll tell you, we also recruited some questionable marketers who know insiders in some facilities. So there are times we are responding to 'ER to home' calls and the patient is outside the ER, smoking cigarettes and leisurely ambulating w/o assistance. Doesn't sound kosher, right? For me, I just right honestly, what I saw, heard, smelled, etc. I don't take it upon myself to make a determination if it's an unbillable call or not. I just get paid by the hour and work within my scope of practice. that's it. I question the new recruits (most of them fresh out of EMT school) and they say our management even provides them a template on how to write their PCRs. And allegedly, there's a portion there that says, "Pt needs an ambulance because________". Man, I can imagine a Medicare suing for fraud for a questionable call. And what's gonna happen? our bosses are gonna just shrug their shoulders and testify, "well, our EMT explicitly stated that the pt needs an ambulance. We weren't on the field, he was". So these poor newbies with dreams of rescuing people and making a difference in the community, etc, might just get hung out to dry, don't you think? Totally uncool.


SECOND: In the vital sign box section at the bottom of our PCR forms, I see our new recruits writing "S/R" right after the heart rates. I asked them what it means and they say "sinus rhythm". I was like, "What!!!? we don't have EKGs! we are BLS!" Just because a pulse is deemed regular, doesn't mean it is a normal sinus rhythm. What if it's a brady, tachy, flutter, Junctional, or a 3rd degree Hb? The point is, a BLS rig doesn't have an EKG! According to the new guy, that's what our FTOs have been telling them to do during orientation. I mean, for the past two years, I just write the whole number without any fancy letters such as S/R, and I never got in any trouble. There were times, I got an irregular pulse, and I just wrote next to the HR number "Irregular". I would also write in my assessments, HR was irregular, or weak, or thready, etc. Why? Because I am BLS! I don't do EKGs! I can only auscultate and palpate. Plus S/R should be SR anyway, referring to a HR that is normal sinus rhythm -- if you have an EKG. It makes me think: if this is a new policy, then why for godsakes is my company not informing me. Makes me think there's a conspiracy to fool the newbies and not inform the veterans because the veterans would definitely either laugh, scratch their heads, or dismiss it as another shenanigan. Supposing they meant "strong, and regular" for S/R, still it is not an approved abbreviation. An EMT should just write the words "strong and regular" next to the heart rate (if there's still space left).

and FINALLY, also in the vital signs section, I see the new guys being instructed to write NTV after the respirations. (example -- 16 NTV). I mean, C'MON! the last time i heard NTV is when they're referring to NASA TV! I was just aghast, i asked the new guy, "hey what does NTV stand for?". The recruit goes, "Oh our FTO says we should write this for "normal tidal volume" . I was like "WTF!". First of all, we have a check box for the type of respirations our patient has. You can select, Normal, Apneic, Labored, etc. So who the hell is coming up with these abbreviations? I found out it's the FTO with a little more than a year's experience on the field, and a biology major. I have nothing against biology majors, but that doesn't give you the right to be inventing abbreviations. Why? Because it looks cool and makes our EMTs look smart? NO! It's totally the opposite.

So guys, correct me if I'm wrong and I'll humbly accept your verdict. But right now, I am just bewildered and don't even know what to think.

Thanks for listening
gastro18

1. For a non-emergent transfer to be a billable run from insurance, one must explain why the pt needs an ambulance, why that pt also requires a stretcher, and why that same pt is unable to sit up in a chair including a wheelchair. You must explain why in detail for each and every question in order to bill insurance.

"CVA" does not count. I've been served by a cashier who had a cerebral aneurysm (stroke) who has lost the use of his left arm. Makes a damn fine cup of coffee. Just has a hard time opening the plastic bag to put my crap in.

"Bilateral Amputee" also does not count. Saw a man in Wal Mart born without a lower torso (body stops above where the hips should be) pushing himself in his wheelchair, getting off, walking on his hands, putting items he wanted to buy in his cart, getting back on and going to the checkout line.

None of these guys need an ambulance for anything. In fact I'll bet you good $$$ that they drive themselves in their own vehicles.

If you can not explain in your assessment and in those question outlined above why you have to transport that pt by ambulance, then you can still transport them. You just can't bill their insurance. Somebody's going to eat that bill: pt, family, hospital, EMS, etc.

2. Also, as a basic level service or any level service for that matter, you can not chart what you cannot prove. If you can not prove the pulse originated in the Sinus Node, then you can not say that it originated in the Sinus Node. If you can not prove that the pt is blowing out a normal tidal volume then you can not say that they are. A spontaneously breathing person would require a measuring device (Wright Spirometer) to measure accurately if they are breathing a normal tidal volume.

Look up your company's Policies and Procedures and follow them.

 

[JPINFV]

1. For a non-emergent transfer to be a billable run from insurance, one must explain why the pt needs an ambulance, why that pt also requires a stretcher, and why that same pt is unable to sit up in a chair including a wheelchair. You must explain why in detail for each and every question in order to bill insurance.

"CVA" does not count. I've been served by a cashier who had a cerebral aneurysm (stroke) who has lost the use of his left arm. Makes a damn fine cup of coffee. Just has a hard time opening the plastic bag to put my crap in.

"Bilateral Amputee" also does not count. Saw a man in Wal Mart born without a lower torso (body stops above where the hips should be) pushing himself in his wheelchair, getting off, walking on his hands, putting items he wanted to buy in his cart, getting back on and going to the checkout line.

None of these guys need an ambulance for anything. In fact I'll bet you good $$$ that they drive themselves in their own vehicles.

If you can not explain in your assessment and in those question outlined above why you have to transport that pt by ambulance, then you can still transport them. You just can't bill their insurance. Somebody's going to eat that bill: pt, family, hospital, EMS, etc.

There are additional reasons besides immobility or being bed confined for ambulance transport (off the top of my head includes psych, communicable diseases requiring isolation, need for monitoring, and many more). Also, I highly doubt that those two are living in facilities where transport would be needed. On the other hand, there are plenty of patients who, for a variety of reasons, are unable to function that independently due to things like amputations or other events in their health history.

2....If you can not prove that the pt is blowing out a normal tidal volume then you can not say that they are. A spontaneously breathing person would require a measuring device (Wright Spirometer) to measure accurately if they are breathing a normal tidal volume.

I'm going to disagree with this because if this is true, then we can't do the opposite. Following this argument, you can't document shallow breathing (low tidal volume) without a spirometer either yet describing (even if it's just a gross observation) the quality of respiration is a normal part of any assessment.

 

[Aidey]

There are additional reasons besides immobility or being bed confined for ambulance transport (off the top of my head includes psych, communicable diseases requiring isolation, need for monitoring, and many more). Also, I highly doubt that those two are living in facilities where transport would be needed. On the other hand, there are plenty of patients who, for a variety of reasons, are unable to function that independently due to things like amputations or other events in their health history.

There are a lot of chronic, managed conditions that are used to "justify" ambulance transfers where I work.

We end up doing a lot of transfers of people who absolutely could and routinely are transported in a wheel chair simply because there is only one wheel chair van available after hours, and one of our hospitals basically refuses to call them. Don't ask me why, it's a management issue. When I've asked the nurses before 'Why isn't this pt going in the van' they look at me like I have two heads and ask "what van?".

There are also facilities that have policies that don't mesh with Medicare's transfer guidelines. One I can think of is that for a communicable disease it has to be active and require isolation precautions to warrant ambulance transfer, however there is a SNF that has the policy that the pt must be transferred by amb if they have had MRSA within the last 10 YEARS, even if they haven't had an active MRSA infection since then. These are people who are under no isolation precautions at the facility, but it's their policy, so we do the transfers.

I would argue that simply writing "CVA" or "BKA" isn't enough, and that it needs to be explained why that condition in that pt qualifies them for transfer. I think there are very few conditions that qualify someone without additional explanation.

I'm going to disagree with this because if this is true, then we can't do the opposite. Following this argument, you can't document
shallow breathing (low tidal volume) without a spirometer either yet describing (even if it's just a gross observation) the quality of respiration is a normal part of any assessment.

I like documenting "adequate" vs "inadequate". I think it more accurately describes the situation without assigning the pt to a category that has a standard value.

 

[gastro18]

Were three threads on the same issue really necessary? Anyway...

I agree with you to a point - you can't tell if a heart rhythm is sinus simply by palpation (ascultation of heart sounds being outside an EMT-B's scope). I would document the pulse by rate, rhythm (regular/irregular) and quality (80 and regular, 60 irregular and thready, Absent, etc.). Same with the respirations. 15 and regular, as opposed to 40 and shallow or irregular, or whatever. If I thought the breathing was biot's or Cheyene-Stokes or Kussmaul, I would put that in my narrative, not that it would be definitive anyway.

As to why the patient needs an amublance... I think that invites trouble. The patient needed an ambulance because they called one. You can't exactly write (if your company wants to get paid) "Patient was ambulatory and appeared to be in no acute distress, but required an ambulance because, 'I don't have a car and need to get to the liquor store near the hospital.'" Or whatever other reasons, beyond a medical emergency, people call ambulances.

Thanks for the reply!
Sir, we (EMT-Bs) are actually authorized to auscultate heart sounds because sometimes the patient circles the drain and next thing you know the patient has no peripheral pulses. Or the patient has no palpable pulses because of the patient's condition (i.e. amputee, obesity, dehydration). The job then is to auscultate for the apical pulse and determine if the patient is still alive, or if the heart is beating irregularly or regularly, or muffled (tamponade), or absent -- heart sounds. Sometimes we get funny sounds too. Of course we are only limited to basic descriptions like "murmur" or "gallops" (extra heart sounds S3, S4), and these too can be documented. We just don't go documenting VSD, Mitral Stenosis, Friction Rubs (even if you know), simply because we are just BLS.

That was funny when you mentioned "liquor store". Because that actually happened to us too.

The thing is, explicitly writing ambulance necessity such as the example mentioned, is like assuming full responsibility as sole decision-maker on who gets to ride an ambulance or not. My position is, as EMTs, we transport, treat, and do assessments to the best of our ability. We don't play around writing "magic words" to make life easy for billing. That's not what we signed up for. That's not why we're getting paid. That job falls on the management level. Billing is getting paid by the company to sort out via paper-shuffling how to justify our independently written PCRs' worthiness to get paid.

Our job is to fill out necessary and pertinent information as required by our PCR sheets, brought about by accurate and honest assessments -- and nothing more.

 

[JPINFV]

The thing is, explicitly writing ambulance necessity such as the example mentioned, is like assuming full responsibility as sole decision-maker on who gets to ride an ambulance or not. My position is, as EMTs, we transport, treat, and do assessments to the best of our ability. We don't play around writing "magic words" to make life easy for billing. That's not what we signed up for. That's not why we're getting paid. That job falls on the management level. Billing is getting paid by the company to sort out via paper-shuffling how to justify our independently written PCRs' worthiness to get paid.

Our job is to fill out necessary and pertinent information as required by our PCR sheets, brought about by accurate and honest assessments -- and nothing more.

Bolded section:
Except... it's not, unless you're lying on your run report. The documentation regarding medical necessity isn't just from the ambulance PCR, but also from the patient's medical record, as attested to by other health care providers (i.e. physician certificate of necessity, which can be signed by several other providers besides physicians). If you are faithfully documenting your assessment, then you're going to be a part of the reason why any call is, or is not billed, and whether a patient is continued to be given service or dropped.


Additionally (and this is directed to the entire concept of the provider as a party to billing), you do like getting paid, correct? The simple fact is that one of the reasons for a PCR is reimbursement for services and this should be one factor in determining how a specific case is documented. The single most important factor? No. Additionally, no factor is worth lying over. Personally, I'd love to see providers docked pay if a continuing lack of proper documentation (lack of proper documentation is not the same as a lack of necessity) leads to billing issues.

 

[gastro18]

Devils advocate, a bradycardia and tachycardia can both be a sinus rhythm and those other rhythms wouldn't present as regular. However, I do agree that "strong and regular" or "regular rate and rhythm" would be a better choice to document at the EMT-B level

Thanks for the reply!

these guys were actually referring to their S/R abbreviations as "NORMAL sinus rhythm". Meaning, NOT an arrhythmia. (I'm sorry if i didn't put the term Normal in there)

a tachy and brady, as we both know, are sinus rhythms. There are P-waves corresponding QRS complexes. but definitely not normal sinus rhythms. they're arrhythmias/dysrhythmias

strong and regular or "regular rate and rhythm" are definitely at the EMT-B level because most EMT-Bs don't do rhythm interpretations for the simple fact that most BLS rigs don't have onboard monitoring, or it's not part of the scope of practice.


Oh by the way.. with 3rd degree hb, flutter, etc, there's a big chance a provider will get a regular rhythm peripheral pulse because each ventricular contraction here is still regular. Which, ultimately would make an EMT-B consider them normal sinus rhythm even though they are significant arrhythmias.

So guys, let's (EMT-Bs) just stick to "strong and regular" "weak and irregular", etc., because Normal Sinus Rhythm is totally an advanced practitioner's (EKG-assisted) finding.

 

[gastro18]

1. For a non-emergent transfer to be a billable run from insurance, one must explain why the pt needs an ambulance, why that pt also requires a stretcher, and why that same pt is unable to sit up in a chair including a wheelchair. You must explain why in detail for each and every question in order to bill insurance.

"CVA" does not count. I've been served by a cashier who had a cerebral aneurysm (stroke) who has lost the use of his left arm. Makes a damn fine cup of coffee. Just has a hard time opening the plastic bag to put my crap in.

"Bilateral Amputee" also does not count. Saw a man in Wal Mart born without a lower torso (body stops above where the hips should be) pushing himself in his wheelchair, getting off, walking on his hands, putting items he wanted to buy in his cart, getting back on and going to the checkout line.

None of these guys need an ambulance for anything. In fact I'll bet you good $$$ that they drive themselves in their own vehicles.

If you can not explain in your assessment and in those question outlined above why you have to transport that pt by ambulance, then you can still transport them. You just can't bill their insurance. Somebody's going to eat that bill: pt, family, hospital, EMS, etc.

2. Also, as a basic level service or any level service for that matter, you can not chart what you cannot prove. If you can not prove the pulse originated in the Sinus Node, then you can not say that it originated in the Sinus Node. If you can not prove that the pt is blowing out a normal tidal volume then you can not say that they are. A spontaneously breathing person would require a measuring device (Wright Spirometer) to measure accurately if they are breathing a normal tidal volume.

Look up your company's Policies and Procedures and follow them.

OMG. Thank God! Finally! someone really understands me! Thanks to you sir!

I've been trying to get my msg across for the last 3 hours now. Man, someone actually told me that the first SVT was diagnosed sometime around the 1600s. I quickly imagined a bearded man from The Medici with an earhorn stuck on a guy's chest, looking up, pausing and saying "Mama mia! Questo Il supraventriculo tachycardi!" How'd he know if it was narrow (<120msec)or widened QRS(>120msec), i can only imagine. Or if it originatd from the SA node or whatever, right? And you're right about the Spirometer. Vt measurement is more than just watching chest rise and fall and absence of cyanosis.

Thank you for speaking up.

 

[Veneficus]

am i not merciful?

Thanks for the reply!
Sir, we (EMT-Bs) are actually authorized to auscultate heart sounds because sometimes the patient circles the drain and next thing you know the patient has no peripheral pulses. Or the patient has no palpable pulses because of the patient's condition (i.e. amputee, obesity, dehydration). The job then is to auscultate for the apical pulse and determine if the patient is still alive, or if the heart is beating irregularly or regularly, or muffled (tamponade), or absent -- heart sounds. Sometimes we get funny sounds too. Of course we are only limited to basic descriptions like "murmur" or "gallops" (extra heart sounds S3, S4), and these too can be documented. We just don't go documenting VSD, Mitral Stenosis, Friction Rubs (even if you know), simply because we are just BLS.

Do I understand you correctly?

You can listen for and document a distant heart tone but not a rub?

You can Report murmers but not a stenosis or regurgitaton? Were you absent that day when they mentioned it is the same thing?

So how do you know that you have an S3 or S4 sound and not a split S2?

I doubt you know the significance. But I'll give you a shot.

Why would S2 be split? What if the split duration is wide vs. narrow? What is happening in the heart? Why is it happening? How do you know you are not hearing a early ejection sound?

When is S3 physiologic? How do you know if it is pathologic?

You said you can hear and document S3 and S4. Did anyone bother to tell you or maybe it was in the book that heart tones correspond to actions of the heart?

That those series of noises can tell you where a signal was originating from?

When you learned the difference between vtach and svt on a monitor you were of course told the electrical activity does not always correspond to the physical activity.

No palpable pulses in an obese person? I have seen patients who weigh 800+ lbs who have readily palpable distal pulses. Press harder.

If a pt has no pulse from dehydration that crosses the line over to life threatening hypovolemia. If they weren't dead they would still have central pulses or you would be doing CPR.

I strongly encourage that if you don't know what you are listening to or for when you listen to heart sounds you not write on a run report you heard specific heart tones. (or even bothered to listen for them until you learn about them)

Those guys in the 1600s clearly were more capable medical providers than today's BLS. Maybe that's why they were called "doctors?"

Incidentally, it was a physician who told me that little gem when he was teaching me how to listen to heart tones and diagnose SVT. (back in 2002)

I'd be happy to hear any more insight you have on the matter. perhaps you would be so gracious as to share your wisdom with me?

I have a few insights on what EMT-B are and are not permitted to do. The next time an EMT-B tells me they can do the same assessment as ALS I am going to just link to this thread.

As one of my favorite professors likes to say "That stethoscope hanging around your neck isn't a piece of jewelry. It has a purpose, learn how to use it."