the art of constructing a clinical narrative art of constructing a clinical... · the art of...

The Art of Constructing a Clinical Narrative

Presented by Douglas M. Wolfberg

www.pwwemslaw.com

5010 E. Trindle Road, Suite 202

Mechanicsburg, PA 17050 717-691-0100

717-691-1226 (fax) [email protected]

Disclaimer: These seminar materials are designed to provide an overview of general legal principles and should not be relied on as legal advice. You should seek advice from an attorney if

you have particular factual situations related to the materials presented here.

© COPYRIGHT 2017, PAGE, WOLFBERG & WIRTH, LLC. ALL RIGHTS RESERVED. REPRODUCTION BY ANY MEANS EXPRESSLY PROHIBITED WITHOUT THE WRITTEN CONSENT OF PAGE, WOLFBERG & WIRTH, LLC.

mailto:[email protected]

2017

Page, Wolfberg & Wirth, LLC ● 5010 E. Trindle Rd., Ste. 202 ● Mechanicsburg, PA 17050

www.pwwemslaw.com ● 717-691-0100 ● Fax – 717-691-1226

Douglas M. Wolfberg Attorney and Consultant

Doug Wolfberg is a founding member of Page, Wolfberg & Wirth. For over 20 years he has been recognized as one of the nation’s most prominent EMS attorneys and consultants. Doug brings a lifelong love of EMS to his work at PWW – he answered his first ambulance call in 1978 and has been involved in EMS ever since. Doug became an EMT at age 16, and worked as an EMS provider and educator in numerous EMS systems over the decades.

Doug has steadily worked up the ladder in his EMS career. He worked as a county EMS director and then as director of a three-county regional EMS agency. He later worked for a statewide EMS council and then went to the nation’s capital to work at the United States Department of Health and Human Services, where he worked on federal EMS and trauma care issues.

After graduating law school with high honors, Doug worked for several years as a health law litigator. He then co-founded PWW in 2000 along with Steve Wirth and the late James O. Page. Doug represents public, private and nonprofit EMS agencies, billing companies, technology companies, private equity firms and others involved in providing and financing EMS. His practice focuses on revenue cycle management and compliance, EMS system design and evaluation, privacy and security, business transactions and other areas of EMS law. Doug serves as faculty at Commonwealth Law School and the University of Pittsburgh, and is a member of the Board of Trustees of Widener University. He has also endowed the Douglas M. Wolfberg Scholarship at Commonwealth Law.

Doug has been a featured presenter at virtually every major EMS conference in the United States and has authored articles and columns in the industry’s best-known publications.

In his free time, Doug is an avid bicyclist and musician.

E-mail: [email protected] Direct Dial: (717) 620-2680 Undergraduate: B.S., Health Planning and Administration The Pennsylvania State University Law School: J.D., Magna Cum Laude Widener University School of Law Commonwealth of Pennsylvania State of New York Supreme Court of the United States U.S. Circuit Court of Appeals, 3rd Circuit U.S. District Court, M.D. PA U.S. District Court, E.D. PA “I consider myself very lucky to be able to combine my lifelong passion for EMS with the practice of law. Having gone from EMT to EMS director to EMS attorney – and to apply that background to serve an industry I care about very deeply – means that I simply love what I do for a living.”

Contact Information

Education

Admissions to Practice

Professional Philosophy

http://www.pwwemslaw.com/

mailto:[email protected]

© Copyright 2017, PWW Media, Inc.

Page 1pwwmedia.com ■ pwwemslaw.com ■ AmbulanceCompliance.com

The Art of Constructing a Clinical Narrative

California Ambulance Association 2017 Annual Convention and Reimbursement Conference

Copyright StatementThe unauthorized reproduction or

distribution of this copyrighted work is illegal. Criminal copyright infringement, including infringement without monetary gain, is investigated by the FBI, and is punishable by up to 5 years in federal

prison and a fine of $250,000.

Disclaimers

This information is presented for educational and general information purposes and should not be relied upon as legal advice or definitive statements of the law. Consult applicable

laws, regulations and policies for officials statements of the law.

No attorney-client relationship is formed by the use of these materials or the participation in this seminar. The user of

these materials bears the responsibility for compliance with all applicable laws and regulations.

Exciting News!

Certified Ambulance Documentation SpecialistTM

The nation’s first – and only – EMS-specific documentation certification course

Specifically designed for EMS practitioners• EMTs/paramedics• QA personnel• Managers/supervisors• Compliance and billing staff


CADSis offered as a one-day preconference workshop at the conference• Hershey, PA – October 23, 2017 • Las Vegas – March 27, 2018• Orlando – April 24, 2018• St. Louis – June 5, 2018




You can also bring CADS to your agency!Course can be done on-site for one flat [email protected]

Course Structure

Lesson 1: EMS Documentation Framework

Lesson 2: Clinical Narratives• 2A – Core Principles of

Clinical Narratives • 2B – Formatting the Clinical

NarrativeLesson 3: Documenting

Consent, Refusals and Special Situations

Lesson 4: Documenting Reimbursement Information

Lesson 5: Documenting Medical Necessity

Lesson 6: Documenting the Reason for Transport

Lesson 7: Signatures

What is a Clinical Narrative?

A clinical narrative is a first person ‘story’ written by an EMS provider that describes a specific patient encounter. The clinical narrative allows the EMS provider to describe complex and often disparate facts in a manner that can be easily understood by others.

Purpose of Narratives

Document the complete story of the call in chronological sequence

Capture all relevant information about the patient’s condition and treatment

What a Good Narrative Should Do

“Paint a picture”

What a Good Narrative Should Do

Above all, the clinical narrative must be accurate It drives coding and reimbursement It is relied upon by governmental and private payers And misrepresentation or falsification can have severe

consequences• Both for the individual provider and the EMS agency



What A Narrative Should Not Do

Not incident reports• Do not use to report information that is not germane to

the call or the patient

Example: • “After the transport, when backing the unit into the

station, the passenger side mirror was inadvertently knocked off.”

What A Narrative Should Not Do

PCRs should not be used to point the finger at another provider or lay blame on another agency

Example:• “First responders on scene had misapplied the

extrication collar and admitted they were unfamiliar with its proper use.”

What a Narrative Should Not Do

It should not be used to boast about the provider’s skills or the agency’s good work

Examples:• “We responded lights and sirens and beat PD to scene.”• “Dispatched mutual aid since neighboring service never gets

out on time”• “Started a 16 gauge because pt was rude”

What a Narrative Should Not Do

It should not purposefully omit information for reimbursement purposes• Example: “Pt was transferred from bed to stretcher”• What really happened: “Pt met us at the front door

with his suitcase in hand and the pt was able to lay down on our stretcher without assistance”

These are actual excerpts from the crew training manual of an ambulance service in Florida… Those excerpts were

attached as Exhibit A to a False Claims

Lawsuit brought by the Department of Justice against the Ambulance

Service in 2016



Narratives in an Age of ePCRs


Constructing a narrative is particularly important now that electronic Patient Care Reports (ePCRs) are dominant

Check boxes, pick lists and automated processes can give the impression that there’s not much left to write in a narrative

Reviewers – medical professionals – are used to writing and reviewing clinical narratives

In fact, narratives are even more critical in the modern mass of data that is an ePCR


“Structured data entry does not support expressiveness and flexibility…and it can be difficult to interpret and reconstruct meaning from structured data due to loss of context...”

Patel, et al., Patients’ understanding of health and biomedical concepts: relationship to the design of EMR systems. Journal of Biomedical Informatics, 2002 Feb:35(1)


Check boxes collect data

Narratives tell stories

Auto Narrative Generation

Some ePCR applications have robust auto-narrative generating capabilities

These can be useful adjuncts to writing a narrativeBut they can never replace human inputs And remember, they are only as complete as the

electronic information that is entered



“The patient complained of

________. Pulse was ___. Blood pressure

was ___/___.”

Template Narratives

Another development brought by ePCRs is the template narrative

Templates can appear to be “cut and paste” and give the implication that a patient-specific assessment was not performed

Template narratives have not been well received by

skeptical prosecutors

and investigators

Regardless of how the

PCR is generated, it

is always critical to

proofread it

A Visual Exercise

Start by thinking of your narrative in visual termsThe PCR is a canvas, your words are the paint

A Visual Exercise

A non-participant should be able to read the chart and see what the crew saw

Descriptive words help to make this process more vivid



Descriptive Words

The use of descriptive words makes a narrative more detailed, objective and accurate

Descriptive Words

Insufficiently Descriptive“Pt was non

cooperative”

More Descriptive“Pt was highly agitated

and hostile when we attempted to ask about past medical history”

Descriptive Words

Insufficiently Descriptive“Altered mental status”

More Descriptive “Pt was lethargic and

could be aroused only upon shouting loud verbal commands. Pt is oriented to person and disoriented to time and place.”

Descriptive Words

Insufficiently Descriptive“Pt gave inappropriate

responses”

More Descriptive “Pt told crew to ‘f#ck

off’ and despite repeated and courteous offers by the crew to take the patient to the hospital, the patient steadfastly refused.”

Examples of Descriptive Words

General Appearance Emaciated Obese Obvious distress No obvious distress

Behavioral

Cooperative Uncooperative Angry Calm

Upset Combative Anxious

Wounds

Open Closed Red White

Black

Dressings

Dry Intact Clean Drainage


Mental StatusAwakeAlert/oriented

Person, place, time, situation

UnresponsiveNon-verbalConfused Lethargic

Extremity Movement Flexion Extension FlaccidContractedGait Limited range of motion



Examples of Descriptive WordsHeart Rate/Pulses Regular Irregular Strong Weak Diminished Bounding

Breathing/Respirations

Airway patent/obstructed Spontaneous Assisted Apnea

Labored Shallow Deep Snoring Gasping

Symmetrical chest rise

Skin Rash Discolored Cyanotic Flushed Mottled Lesions Bruised Ulcerated


Abdomen Enlarged Distended Protruding Rigid Tender Soft/relaxed

Quantities ProfuseCopious ExcessiveModerate Slight

Principles of a Good

Narrative

Seven Principles of a Good Narrative

CompleteObjective SpecificDispassionateConsistentProfessionalChronological

Complete

Contains all relevant informationDoes not purposefully omit relevant informationCaptures all aspects of operations, assessment,

treatment, transport and patient disposition

Be Complete! Incomplete:

“Pt was found supine in bed”

More Complete : “Pt was found in a hospital bed in the bedroom, supine, 30° upright calmly speaking to his son, skin pale but in no obvious distress. On oxygen 2 LPM nasal cannula. Pt was unable to get up from bed without assistance and could not be transported by other means due to severe sacral wound to L buttocks Stage 4 per visiting nurse at home. Pt had to be sheet pulled onto stretcher by four personnel and was unable to offer any assistance. Pt very weak and has frequent syncopal episodes when sitting up”



Objective vs. Subjective

Objective

Documentation should be objective, not subjective

Objective Subjective-Facts -Opinion-Unbiased -Unsupported conclusions

Examples

Subjective:• “Pt appears to be intoxicated at the present time.”

Objective:• “Pt has noticeable odor of alcoholic beverages on breath. Pt’s

speech is slurred and pt admits drinking 6 beers in the past 30 minutes.”

Objective

The patient may report subjective information, but the fact that the patient reports it makes it objective • It’s a fact of what the patient reported

Example: • “Pt states that it feels like an elephant is sitting on his chest”

Objective

Whenever possible, be quantitative as well as qualitative

Quantitative:• Specific numbers or values

Qualitative • Fact-based descriptions

“Pt describes the pain as ‘sharp’ and ‘stabbing’. Pt rates

pain an 8 on a 1-10 scale.”

Qualitative Quantitative



A Good Narrative is Specific

Specificity

This is more critical than ever with the implementation of new diagnosis codes (ICD-10) that are required on all ambulance claims

This requires more precision both in terms of anatomic landmarks and geographic locations

Examples: SpecificityInadequate“Pt was found in bed and transferred from bed to stretcher”

Specific“Pt was found in hospital bed in Room 206 in supine position unresponsive to voice with arms and legs flaccid. Pt was log rolled onto side and then back onto a sheet. Moved to stretcher via a sheet pull method by 4 people and secured in a supine position on the stretcher with four cot straps. Pt remained unresponsive to voice during transport”

Examples: SpecificityInadequate“Patient fell, complains of pain in right shoulder”

Specific“Patient was at work at an industrial warehouse when patient fell from a forklift moving at approximately 1mph. Patient has noticeable abrasions and red skin on right anterior shoulder area as well as right posterior scapular area, approximately 2” from top of shoulder.”

Examples: SpecificityInadequate“Pt has decubitus ulcer on R buttocks”

Specific“Pt has approx. 4” decubitus ulcer on right side upper of buttocks, located approximately ½” distally from sacrum. According to SNF staff, wound is Stage 3 and pt experiences severe pain on movement, making it impossible for pt to sit in a chair or wheelchair.”

A Good Narrative is “Dispassionate”



Dispassionate

Dispassionate means that your chart is not influenced by emotion, bias or personal feelings

A PCR is not the place to let life’s frustrations bubble to the surface

“Dispatched by 911 for SOB at 03:00. AOS to find a 75 y/o female shuffling around kitchen with absolutely no complaints. Pt. says she has a cardiac history and was SOB earlier in the day, but feels fine now. Pt did not need an ambulance, no way, no how. This was a waste of my time. Walked pt to stretcher and transported to ABC Medical Center, transport uneventful”

Dispassionate?

Consistent

Ensure your PCR does not contain inconsistencies• In the narrative itself• Between the narrative and the data portions of the PCR• With other accurate clinical documentation regarding

the patient’s condition on the date of service

Example: Inconsistent Mobility Status

“Pt is bed confined. Pt was in her wheelchair when she slipped and fell trying to get up”

Example: Inconsistent Anatomical Assessment

Example: Inconsistent Mental Status

“Patient is A & O x 4 with GCS of 6”



Professional

Accurate and appropriate terminology suitable for your scope of practice

Grammatically correctProper spellingProper syntax DON’T USE ALL CAPS!

Terminology

It is time for EMTs and medics to brush off their old anatomy, physiology and terminology notes and use them!

PCRs must be presented in an objective, clinical manner to:-Support coding -Obtain legitimate reimbursement-Ensure compliance -Reduce liability

Compare

“Pt has possible broken leg”

“Pt has possible fracture of right distal tib/fib, approximately 5” above ankle, located anteriorly. Lower leg angulated at approximately 40o”

Documenting Within Scope of Practice

It is common for BLS and ALS providers to work together in providing patient care

In some instances, such as paramedic intercepts, EMTs and medics may produce separate PCRs

Providers should be careful to document within their scope of practice

Compare These BLS PCRs…

“Paramedic Smith applied a cardiac

monitor.”Within the BLS

scope of practice

“Paramedic Smith applied a 12-lead cardiac monitor,

which showed sinus rhythm with occasional

PVCs”

Outside the BLS scope of practice

Spelling and Grammar

Nothing makes a PCR seem less professional – and the providers less competent – than misspelled words and poor grammar



Abbreviations

When using abbreviations, it is important only to utilize those that are commonly understood and accepted

No “home grown” abbreviations

Syntax

Syntax refers to the arrangement of words and phrases to create complete and well-formed sentences

Example - Syntax

“Patient cannot completely raise right arm. Or right hand due to pain.”

“Patient cannot completely raise right arm and cannot raise right hand at all due to pain.”

Chronological

Narrative should flow in sequence“DRAATT” chronological narrative format

DRAATT Chronological Narrative Format

DispatchResponseArrival AssessmentTreatment Transport



DispatchNarrative should begin with nature of the call at time

dispatch This is a critical element that determines proper level

and type of service• Emergency vs. Non-Emergency• ALS vs. BLS (ALS Assessment rule)

Should include nature and location of the call as well as any response determinants issued by the dispatcher

Dispatch

Examples:• “Dispatched Emergency by 911 for chest pains to a

residence at 123 Main Street…”• “Dispatched 30-D-3 for major trauma at XYZ

Industries…”

Response

Documenting information about the response mode also is important for liability, reimbursement and compliance

This can be done in conjunction with the dispatch documentation but should not be overlooked

Response

Examples:• “Responded with lights and sirens…”

Arrival

Narrative should document a size-up of the scene“Paint the picture” as to what the crew encountered,

observations that may impact mechanism of injury, overall appearance of scene, etc.

Arrival “Arrived on scene to find a

motor vehicle crash with two vehicles involved. Vehicle 1 appeared to be a compact passenger vehicle with 3 visible occupants and Vehicle 2 with one occupant standing outside the vehicle, which was a fuel tanker truck that appeared to be leaking a fluid onto the roadway.”



Arrival

“Arrived at XYZ Assisted Living Facility, Room 216, to find an elderly male patient, seated in a chair. Patient’s eyes were closed and he was receiving supplemental oxygen via nasal cannula, but appeared to be resting comfortably as we entered the room.”

Assessment

Documentation of a thorough patient assessment is a key component of a good clinical narrative

A narrative with insufficient documentation of the patient assessment probably means that there was an incomplete assessment

Assessment: General Impression

Immediate life threatsChief Complaint - identification of the patient’s

primary problem – usually, but not always in their own words

Trauma or medical?

Assessment: Mental Status

AVPU• Alert• Responds to verbal stimulus• Responds to painful stimulus• Unresponsive

Altered mental status?

Assessment: ABC

Airway• Patent airway?• Snoring,

gurgling, crowing, stridor, etc.?

• Obstruction?

Breathing• Spontaneous

respirations?• Breath sounds?• Chest rise/fall?• Difficulty

breathing – use of accessory muscles, nasal flaring?

Circulation• Pulse?• Normal?• Strong?• Regular?• Major bleeds?

Assessment:Focused History & Exam: Trauma

Documentation of rapid trauma assessment “DCAP-BTLS”

• Deformities• Contusions• Abrasions• Punctures/penetrations

• Burns• Tenderness• Lacerations• Swelling



Assessment: Focused History & Exam: Trauma

Documentation of systems assessment:• Head and face• Neck• Chest• Abdomen• Pelvis• Extremities• Back

Assessment:Focused History and Exam: Medical

Documentation of rapid medical assessment• Pertinent past medical history• Medications and allergies• Baseline vitals• Review of body systems

Assessment:The “SAMPLE” History

Signs and symptoms AllergiesMedications Pertinent past historyLast oral intakeEvents leading up to injury or illness

Assessment: Documenting Pain

Pain is a very common complaint encountered by EMS practitioners

On its own, “pain” is non-specific and can be subjective

Express it in objective, clinical terms

Assessment: Documenting Pain

The OPQRST approach should be used anytime pain is documented as a clinical finding

OPQRST

OnsetProvocation or palliationQualityRegion and radiationSeverityTime (history)



Example

Constructing an OPQRST Narrative

Example “Pt reports chest pain which began at approximately 0545 today.

Pt was laying in bed when pain began and was not physically active at the time. Pt states that pain is not affected by movement and there is no position that makes it better or worse. Pt describes the pain as “achy” and “hot”. Pt reports that pain is located in the center of the chest, approximately 2” below nipple line. Pt rates pain as a 6 on 1-10 scale. Pt reports that pain was intermittent for the first hour then became constant.”

O P Q R S T

Treatment

Documenting the clinical interventions provided to the patient is another key component of the clinical narrative

But your narrative must do more than merely identify the treatment provided

Treatment

Treatment narratives should always address three things:• Clinical indications for the treatment• The treatment/intervention• Results of the treatment/intervention

In Other Words, Answer These Three Questions:

FIRST – Why did you do it?SECOND – What did you do?THIRD – How did it go?

Treatment - Examples

“Due to patient’s ashen appearance, shortness of breath and SPO2 of 90% on room air, EMT Jones started pt on oxygen at 6 liters via simple face mask. Following initial application of oxygen, patient reported the SOB had improved. After 5 minutes, reassessed patient and SPO2 was 94%...”



Treatment - Examples

“Because patient reported pain from the open fracture of the R tib/fib as 9/10, with no relief from immobilization, we administered 2 mg MS via slow IV push. 5 minutes following administration, pt reported moderate improvement of pain as a 7/10.”

Transport

Narrative should document essential facts about the transport and disposition of the patient:• Transport mode to destination (lights/sirens, etc.)• Description of destination (hospital, SNF, assisted living,

etc.)• Reason for bypassing closer destination (if applicable)

Transport

Narrative should document essential facts about the transport and disposition of the patient:• Condition of patient upon arrival at destination, including

any clinically significant changes from earlier assessments• Handoff of care, including identity of person assuming

responsibility for care

Remember, DRAATT

DRAATT Chronological Narrative

Format

DispatchResponseArrival AssessmentTreatment Transport

Visit PWW

Visit our EMS Law Website at www.pwwemslaw.com

the art of constructing a clinical narrative art of constructing a clinical... · the art of...

Documents